health financial systems in lieu of form cms-2552-10 ...€¦ · in column 2, enter "y"...

In Lieu of Form CMS-2552-10Health Financial Systems

FORM APPROVED

OMB NO. 0938-0050

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Falure to report can result in all interim

payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).

Date/Time Prepared:

Worksheet S

Parts I-III

5/24/2012 1:37 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT CERTIFICATION

AND SETTLEMENT SUMMARY

PART I - COST REPORT STATUS

Provider

use only

[ X ] Electronically filed cost report Date: 5/24/2012 Time: 1:37 pm

[ X ] Manually submitted cost report

[ 0 ] If this is an amended report enter the number of times the provider resubmitted this cost report

Contractor

use only

[ 0 ]Cost Report Status

(1) As Submitted

(2) Settled without Audit

(3) Settled with Audit

(4) Reopened

(5) Amended

Date Received:

Contractor No.

NPR Date:

Medicare Utilization. Enter "F" for full or "L" for low.

Contractor's Vendor Code:

[ 0 ]If line 5, column 1 is 4: Enter

number of times reopened = 0-9.

[ N ]

04

Initial Report for this Provider CCN

Final Report for this Provider CCN[ N ]

1.

2.

3.

4.

5. 6.

7.

8.

9.

10.

11.

12.

[ F ]

PART II - CERTIFICATION

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND

ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE

PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND

ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.

CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)

I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically

filed or manually submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by

ADVOCATE CHRIST HOSPITAL for the cost reporting period beginning 01/01/2011 and ending 12/31/2011 and to the

best of my knowledge and belief, it is a true, correct and complete statement prepared from the books and

records of the provider in accordance with applicable instructions, except as noted. I further certify that I

am familiar with the laws and regulations regarding the provision of health care services identified in this

cost report were provided in compliance with such laws and regulations.

(Signed)

Officer or Administrator of Provider(s)

Title

Date

Title XVIII

Cost Center Description Title V Part A Part B HIT Title XIX

1.00 2.00 3.00 4.00 5.00

PART III - SETTLEMENT SUMMARY

1.00 Hospital 0 5,032,251 1,405,271 2,859,207 0 1.00

2.00 Subprovider - IPF 0 3,620 0 0 2.00

3.00 Subprovider - IRF 0 17,647 0 0 3.00

4.00 SUBPROVIDER I 0 0 0 0 4.00

5.00 Swing bed - SNF 0 0 0 0 5.00

6.00 Swing bed - NF 0 0 6.00

7.00 SKILLED NURSING FACILITY 0 0 0 0 7.00

8.00 NURSING FACILITY 0 0 8.00

9.00 HOME HEALTH AGENCY I 0 0 0 0 9.00

10.00 RURAL HEALTH CLINIC I 0 0 0 10.00

11.00 FEDERALLY QUALIFIED HEALTH CENTER I 0 0 0 11.00

12.00 CMHC I 0 0 0 12.00

200.00 Total 0 5,053,518 1,405,271 2,859,207 0 200.00

The above amounts represent "due to" or "due from" the applicable program for the element of the above complex indicated.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0050. The time

required to complete and review the information collection is estimated 673 hours per response, including the time to review

instructions, search existing resources, gather the data needed, and complete and review the information collection. If you

have any comments concerning the accuracy of the time estimate(s) or suggestions for improving the form, please write to: CMS,

7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

ADVOCATE CHRIST HOSPITAL

MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX IDENTIFICATION DATA

1.00 2.00 3.00 4.00

Hospital and Hospital Health Care Complex Address:

1.00 Street:4440 WEST 95TH STREET PO Box: 1.00

2.00 City: OAK LAWN State: IL Zip Code: 60453- County: COOK 2.00

Component Name

1.00

CCN

Number

2.00

CBSA

Number

3.00

Provider

Type

4.00

Date

Certified

5.00

Payment System (P,

T, O, or N)

V

6.00

XVIII

7.00

XIX

8.00

Hospital and Hospital-Based Component Identification:

3.00 Hospital ADVOCATE CHRIST

HOSPITAL

140208 29404 1 07/01/1966 N P O 3.00

4.00 Subprovider - IPF ADVOCATE CHRIST

HOSPITAL - PSYCH

14S208 29404 4 01/01/1984 N P O 4.00

5.00 Subprovider - IRF ADVOCATE CHRIST

HOSPITAL - REHAB

14T208 29404 5 01/01/1984 N P O 5.00

6.00 Subprovider - (Other) 6.00

7.00 Swing Beds - SNF N N N 7.00

8.00 Swing Beds - NF N N 8.00

9.00 Hospital-Based SNF 9.00

10.00 Hospital-Based NF 10.00

11.00 Hospital-Based OLTC 11.00

12.00 Hospital-Based HHA 12.00

13.00 Separately Certified ASC 13.00

14.00 Hospital-Based Hospice 14.00

15.00 Hospital-Based Health Clinic - RHC N N N 15.00

16.00 Hospital-Based Health Clinic - FQHC N N N 16.00

17.00 Hospital-Based (CMHC) 1 17.00

17.10 Hospital-Based (CORF) 1 N N N 17.10

18.00 Renal Dialysis 18.00

19.00 Other 19.00

From:

1.00

To:

2.00

20.00 Cost Reporting Period (mm/dd/yyyy) 01/01/2011 12/31/2011 20.00

21.00 Type of Control (see instructions) 1 21.00

Inpatient PPS Information

22.00 Does this facility qualify for and is it currently receiving payments for

disproportionate share hospital adjustment, in accordance with 42 CFR §412.106? In

column 1, enter "Y" for yes or "N" for no. Is this facility subject to 42 CFR Section

§412.06(c)(2)(Pickle amendment hospital?) In column 2, enter "Y" for yes or "N" for no.

Y N 22.00

23.00 Indicate in column 1 the method used to capture Medicaid (title XIX) days reported on

lines 24 and/or 25 of this worksheet during the cost reporting period by entering a "1"

if days are based on the date of admission, "2" if days are based on census days (also

referred to as the day count), or "3" if the days are based on the date of discharge.

Is the method of identifying the days in the current cost reporting period different

from the method used in the prior cost reporting period? Enter in column 2 "Y" for yes

or "N" for no.

2 N 23.00

In-State

Medicaid

paid days

1.00

In-State

Medicaid

eligible

days

2.00

Out-of

State

Medicaid

paid days

3.00

Out-of

State

Medicaid

eligible

days

4.00

Medicaid

HMO days

5.00

Other

Medicaid

days

6.00

24.00 If line 22 and/or line 45 is "yes", and this

provider is an IPPS hospital enter the in-state

Medicaid paid days in col. 1, in-state Medicaid

eligible days in col. 2, out-of-state Medicaid paid

days in col. 3, out-of-state Medicaid eligible days

in col. 4, Medicaid HMO days in col. 5, and other

Medicaid days in col. 6.

25,483 25,937 1,505 503 0 0 24.00

25.00 If this provider is an IRF, enter the in-State

Medicaid paid days in column 1, the in State

Medicaid eligible days in column 2, the out of State

Medicaid paid days in column 3, the out of State

Medicaid eligible days in column 4, Medicaid HMO

days in column 5, and other Medicaid days in column

6. For all columns include in these days the labor

and delivery days.

257 416 0 0 0 0 25.00

Urban/Rural S

1.00

Date of Geogr

2.00

26.00 Enter your standard geographic classification (not wage) status at the beginning of the

cost reporting period. Enter (1) for urban or (2) for rural.

1 26.00

27.00 For the Standard Geographic classification (not wage), what is your status at the end

of the cost reporting period. Enter (1) for urban or (2) for rural. If applicable,

enter the effective date of the geographic reclassification (in column 2).

1 27.00

35.00 If this is a sole community hospital (SCH), enter the number of periods SCH status in

effect in the cost reporting period.

0 35.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Beginning:

1.00

Ending:

2.00

36.00 Enter applicable beginning and ending dates of SCH status. Subscript line 36 for number

of periods in excess of one and enter subsequent dates.

36.00

37.00 If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status

in effect in the cost reporting period.

0 37.00

38.00 Enter applicable beginning and ending dates of MDH status. Subscript line 38 for number

of periods in excess of one and enter subsequent dates.

38.00

V

1.00

XVIII

2.00

XIX

3.00

Prospective Payment System (PPS)-Capital

45.00 Does this facility qualify and receive Capital payment for disproportionate share in accordance

with 42 CFR Section §412.320? (see instructions)

N Y N 45.00

46.00 Is this facility eligible for the special exceptions payment pursuant to 42 CFR Section

§412.348(g)? If yes, complete Worksheet L, Part III and L-1, Parts I through III

N N N 46.00

47.00 Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes or "N" for no. N N N 47.00

48.00 Is the facility electing full federal capital payment? Enter "Y" for yes or "N" for no. N N N 48.00

Teaching Hospitals

56.00 Is this a hospital involved in training residents in approved GME programs? Enter "Y" for yes

or "N" for no.

Y 56.00

57.00 If line 56 is yes, is this the first cost reporting period during which residents in approved

GME programs trained at this facility? Enter "Y" for yes or "N" for no in column 1. If column 1

is "Y" did residents start training in the first month of this cost reporting period? Enter "Y"

for yes or "N" for no in column 2. If column 2 is "Y", complete Worksheet E-4. If column 2 is

"N", complete Worksheet D, Part III & IV and D-2, Part II, if applicable.

N 57.00

58.00 If line 56 is yes, did this facility elect cost reimbursement for physicians' services as

defined in CMS Pub. 15-1, section 2148? If yes, complete Worksheet D-5.

N 58.00

59.00 Are costs claimed on line 100 of Worksheet A? If yes, complete Worksheet D-2, Part I. N 59.00

60.00 Are you claiming nursing school and/or allied health costs for a program that meets the

provider-operated criteria under §413.85? Enter "Y" for yes or "N" for no. (see instructions)

Y 60.00

Y/N

1.00

IME Average

2.00

Direct GME

Average

3.00

61.00 Did your facility receive additional FTE slots under ACA section 5503?

Enter "Y" for yes or "N" for no in column 1. If "Y", effective for

portions of cost reporting periods beginning on or after July 1, 2011

enter the average number of primary care FTE residents for IME in column

2 and direct GME in column 3, from the hospital’s three most recent cost

reports ending and submitted before March 23, 2010. (see instructions)

N 0.00 0.00 61.00

ACA Provisions Affecting the Health Resources and Services Administration (HRSA)

62.00 Enter the number of FTE residents that your hospital trained in this

cost reporting period for which your hospital received HRSA PCRE funding

(see instructions)

0.00 62.00

62.01 Enter the number of FTE residents that rotated from a Teaching Health

Center (THC) into your hospital during in this cost reporting period of

HRSA THC program. (see instructions)

0.00 62.01

Teaching Hospitals that Claim Residents in Non-Provider Settings

63.00 Has your facility trained residents in non-provider settings during this

cost reporting period? Enter "Y" for yes or "N" for no. If yes,

complete lines 64-67. (see instructions)

N 63.00

Unweighted

FTEs

Nonprovider

Site

1.00

Unweighted

FTEs in

Hospital

2.00

Ratio (col. 1/

(col. 1 + col.

2))

3.00

Section 5504 of the ACA Base Year FTE Residents in Nonprovider settings--This base year is your cost reporting

period that begins on or after July 1, 2009 and before June 30, 2010.

64.00 If line 63 is yes or your facility trained residents in the base year

period, enter in column 1, from your cost reporting period that begins

on or after July 1, 2009, and before June 30, 2010 the number of

unweighted nonprimary care FTE residents attributable to rotations that

occurred in all nonprovider settings. Enter in column 2 the number of

unweighted nonprimary care FTE residents that trained in your hospital.

Include unweighted OB/GYN, dental and podiatry FTEs on this line. Enter

in column 3, the ratio of column 1 divided by the sum of columns 1 and

2.

2.53 12.67 0.166447 64.00

1.00

Program Name Program Code

2.00

Unweighted

FTEs

Nonprovider

Site

3.00

Unweighted

FTEs in

Hospital

4.00

Ratio (col. 3/

(col. 3 + col.

4))

5.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


1.00


2.00

Unweighted

FTEs

Nonprovider

Site

3.00

Unweighted

FTEs in

Hospital

4.00

Ratio (col. 3/

(col. 3 + col.

4))

5.00

65.00 If line 63 is yes or your

facility trained residents in

the base year period, enter

from your cost reporting period

that begins on or after July 1,

2009 and before June 30, 2010,

the number of unweighted

primary care FTE residents for

each primary care specialty

program in which you train

residents. Use subscripted

lines 65.01 through 65.50 for

each additional primary care

program. Enter in column 1, the

program name. Enter in column

2, the program code. Enter in

column 3, the number of

unweighted primary care FTE

residents attributable to

rotations that occurred in

nonprovider settings for each

applicable program. Enter in

column 4, the number of

unweighted primary care FTE

residents in your hospital for

each applicable program. Enter

in column 5 the ratio of column

3 divided by the sum of columns

3 and 4.

65.000.18029162.4713.741400INTERNAL MEDICINE

65.01 65.010.17355439.008.192000PEDIATRICS

Unweighted

FTEs

Nonprovider

Site

1.00

Unweighted

FTEs in

Hospital

2.00

Ratio (col. 1/

(col. 1 + col.

2))

3.00

Section 5504 of the ACA Current Year FTE Residents in Nonprovider settings--Effective for cost reporting periods

beginning on or after July 1, 2010

66.00 Enter in column 1 the number of unweighted non-primary care resident

FTEs attributable to rotations occurring in all non-provider settings.

Enter in column 2 the number of unweighted non-primary care resident

FTEs that trained in your hospital. Enter in column 3 the ratio of

(column 1 divided by (column 1 + column 2)). (see instructions)

2.81 14.04 0.166766 66.00

1.00


2.00

Unweighted

FTEs

Nonprovider

Site

3.00

Unweighted

FTEs in

Hospital

4.00

Ratio (col. 3/

(col. 3 + col.

4))

5.00

67.00 Enter in column 1 the program

name. Enter in column 2 the

program code. Enter in column

3 the number of unweighted

primary care FTE residents

attributable to rotations

occurring in all non-provider

settings. Enter in column 4 the

number of unweighted primary

care resident FTEs that trained

in your hospital. Enter in

column 5 the ratio of (column 3

divided by (column 3 + column

4)). (see instructions)

67.000.18035854.0811.901400INTERNAL MEDICINE

67.01 67.010.1874297.111.643900INTERNAL MEDICINE

67.02 67.020.17363519.374.072000PEDIATRICS

67.03 67.030.17345118.683.925250PEDIATRICS

1.00 2.00 3.00

Inpatient Psychiatric Facility PPS

70.00 Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider?

Enter "Y" for yes or "N" for no.

Y 70.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


1.00 2.00 3.00

71.00 If line 70 yes: Column 1: Did the facility have a teaching program in the most recent cost

report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no. Column 2: Did

this facility train residents in a new teaching program in accordance with 42 CFR §412.424

(d)(1)(iii)(D)? Enter "Y" for yes or "N" for no. Column 3: If column 2 is Y, enter 1, 2 or 3

respectively in column 3. (see instructions) If this cost reporting period covers the beginning

of the fourth year, enter 4 in column 3, or if the subsequent academic years of the new teaching

program in existence, enter 5. (see instructions)

N N 0 71.00

Inpatient Rehabilitation Facility PPS

75.00 Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF

subprovider? Enter "Y" for yes and "N" for no.

Y 75.00

76.00 If line 75 yes: Column 1: Did the facility have a teaching program in the most recent cost

reporting period ending on or before November 15, 2004? Enter "Y" for yes or "N" for no. Column

2: Did this facility train residents in a new teaching program in accordance with 42 CFR

§412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no. Column 3: If column 2 is Y, enter 1, 2

or 3 respectively in column 3. (see instructions) If this cost reporting period covers the

beginning of the fourth year, enter 4 in column 3, or if the subsequent academic years of the

new teaching program in existence, enter 5. (see instructions)

N N 0 76.00

1.00

Long Term Care Hospital PPS

80.00 Is this a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no. N 80.00

TEFRA Providers

85.00 Is this a new hospital under 42 CFR Section §413.40(f)(1)(i) TEFRA? Enter "Y" for yes or "N" for no. N 85.00

86.00 Did this facility establish a new Other subprovider (excluded unit) under 42 CFR Section

§413.40(f)(1)(ii)? Enter "Y" for yes and "N" for no.

N 86.00

V

1.00

XIX

2.00

Title V or XIX Inpatient Services

90.00 Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for

yes or "N" for no in the applicable column.

N Y 90.00

91.00 Is this hospital reimbursed for title V and/or XIX through the cost report either in

full or in part? Enter "Y" for yes or "N" for no in the applicable column.

N N 91.00

92.00 Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see

instructions) Enter "Y" for yes or "N" for no in the applicable column.

N 92.00

93.00 Does this facility operate an ICF\MR facility for purposes of title V and XIX? Enter

"Y" for yes or "N" for no in the applicable column.

N N 93.00

94.00 Does title V or XIX reduce capital cost? Enter "Y" for yes, and "N" for no in the

applicable column.

N N 94.00

95.00 If line 94 is "Y", enter the reduction percentage in the applicable column. 0.00 0.00 95.00

96.00 Does title V or XIX reduce operating cost? Enter "Y" for yes or "N" for no in the

applicable column.

N N 96.00

97.00 If line 96 is "Y", enter the reduction percentage in the applicable column. 0.00 0.00 97.00

Rural Providers

105.00 Does this hospital qualify as a Critical Access Hospital (CAH)? N 105.00

106.00 If this facility qualifies as a CAH, has it elected the all-inclusive method of payment

for outpatient services? (see instructions)

N 106.00

107.00 Column 1: If this facility qualifies as a CAH, is it eligible for cost reimbursement

for I &R training programs? Enter "Y" for yes or "N" for no in column 1. (see

instructions) If yes, the GME elimination would not be on Worksheet B, Part I, column

25 and the program would be cost reimbursed. If yes complete Worksheet D-2, Part II.

Column 2: If this facility is a CAH, do I&Rs in an approved medical education program

train in the CAH's excluded IPF and/or IRF unit? Enter "Y" for yes or "N" for no in

column 2. (see instructions)

N 107.00

108.00 Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42

CFR Section §412.113(c). Enter "Y" for yes or "N" for no.

N 108.00

Physical

1.00

Occupational

2.00

Speech

3.00

Respiratory

4.00

109.00 If this hospital qualifies as a CAH or a cost provider, are

therapy services provided by outside supplier? Enter "Y"

for yes or "N" for no for each therapy.

N N N N 109.00

1.00 2.00

Miscellaneous Cost Reporting Information

115.00 Is this an all-inclusive rate provider? Enter "Y" for yes or "N" for no in column 1. If

yes, enter the method used (A, B, or E only) in column 2.

N 115.00

116.00 Is this facility classified as a referral center? Enter "Y" for yes or "N" for no. N 116.00

117.00 Is this facility legally-required to carry malpractice insurance? Enter "Y" for yes or

"N" for no.

N 117.00

118.00 Is the malpractice insurance a claims-made or occurrence policy? Enter 1 if the policy

is claim-made. Enter 2 if the policy is occurrence.

1 118.00

119.00 What is the liability limit for the malpractice insurance policy? Enter in column 1

the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year.

257,500,000 257,500,000119.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


1.00 2.00

120.00 Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA

§3121 as amended by the Medicaid Extender Act (MMEA) §108? Enter in column 1 "Y" for

yes or "N" for no. Is this a rural hospital with <= 100 beds that qualifies for the

Outpatient Hold Harmless provision in ACA §3121? Enter in column 2 "Y" for yes or "N"

for no.

N N 120.00

121.00 Did this facility incur and report costs for implantable devices charged to patients?


Y 121.00

Transplant Center Information

125.00 Does this facility operate a transplant center? Enter "Y" for yes and "N" for no. If

yes, enter certification date(s) (mm/dd/yyyy) below.

N 125.00

126.00 If this is a Medicare certified kidney transplant center, enter the certification date

in column 1 and termination date, if applicable, in column 2.

126.00

127.00 If this is a Medicare certified heart transplant center, enter the certification date


127.00

128.00 If this is a Medicare certified liver transplant center, enter the certification date


128.00

129.00 If this is a Medicare certified lung transplant center, enter the certification date in

column 1 and termination date, if applicable, in column 2.

129.00

130.00 If this is a Medicare certified pancreas transplant center, enter the certification

date in column 1 and termination date, if applicable, in column 2.

130.00

131.00 If this is a Medicare certified intestinal transplant center, enter the certification

date in column 1 and termination date, if applicable, in column 2.

131.00

132.00 If this is a Medicare certified islet transplant center, enter the certification date


132.00

133.00 If this is a Medicare certified other transplant center, enter the certification date


133.00

134.00 If this is an organ procurement organization (OPO), enter the OPO number in column 1

and termination date, if applicable, in column 2.

134.00

All Providers

140.00 Are there any related organization or home office costs as defined in CMS Pub. 15-1,

chapter 10? Enter "Y" for yes or "N" for no in column 1. If yes, and home office costs

are claimed, enter in column 2 the home office chain number. (see instructions)

Y 14H036 140.00

1.00 2.00 3.00

If this facility is part of a chain organization, enter on lines 141 through 143 the name and address of the

home office and enter the home office contractor name and contractor number.

141.00 Name: ADVOCATE HEALTH CARE Contractor's Name: NGS Contractor's Number: 00131 141.00

142.00 Street:2025 WINDSOR DRIVE PO Box: 142.00

143.00 City: OAK BROOK State: IL Zip Code: 60523 143.00

1.00

144.00 Are provider based physicians' costs included in Worksheet A? Y 144.00

145.00 If costs for renal services are claimed on Worksheet A, are they costs for inpatient services only?


Y 145.00

1.00 2.00

146.00 Has the cost allocation methodology changed from the previously filed cost report?

Enter "Y" for yes or "N" for no in column 1. (See CMS Pub. 15-2, section 4020) If yes,

enter the approval date (mm/dd/yyyy) in column 2.

N 146.00

147.00 Was there a change in the statistical basis? Enter "Y" for yes or "N" for no. N 147.00

148.00 Was there a change in the order of allocation? Enter "Y" for yes or "N" for no. N 148.00

149.00 Was there a change to the simplified cost finding method? Enter "Y" for yes or "N" for

no.

N 149.00

Part A

1.00

Part B

2.00

Does this facility contain a provider that qualifies for an exemption from the application of the lower of costs

or charges? Enter "Y" for yes or "N" for no for each component for Part A and Part B. (See 42 CFR §413.13)

155.00 Hospital N N 155.00

156.00 Subprovider - IPF N N 156.00

157.00 Subprovider - IRF N N 157.00

158.00 SUBPROVIDER N N 158.00

159.00 SNF N N 159.00

160.00 HOME HEALTH AGENCY N N 160.00

161.00 CMHC N 161.00

161.10 CORF N 161.10

1.00

Multicampus

165.00 Is this hospital part of a Multicampus hospital that has one or more campuses in different CBSAs?


N 165.00

Name

0

County

1.00

State

2.00

Zip Code

3.00

CBSA

4.00

FTE/Campus

5.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Name

0

County

1.00

State

2.00

Zip Code

3.00

CBSA

4.00

FTE/Campus

5.00

166.00 If line 165 is yes, for each

campus enter the name in column

0, county in column 1, state in

column 2, zip code in column 3,

CBSA in column 4, FTE/Campus in

column 5

0.00166.00

1.00

Health Information Technology (HIT) incentive in the American Recovery and Reinvestment Act

167.00 Is this provider a meaningful user under Section §1886(n)? Enter "Y" for yes or "N" for no. Y 167.00

168.00 If this provider is a CAH (line 105 is "Y") and is a meaningful user (line 167 is "Y"), enter the

reasonable cost incurred for the HIT assets (see instructions)

0168.00

169.00 If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the

transition factor. (see instructions)

1.00169.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL AND HOSPITAL HEALTH CARE REIMBURSEMENT QUESTIONNAIRE

Y/N Date

1.00 2.00

General Instruction: Enter Y for all YES responses. Enter N for all NO responses. Enter all dates in the

mm/dd/yyyy format.

COMPLETED BY ALL HOSPITALS

Provider Organization and Operation

1.00 Has the provider changed ownership immediately prior to the beginning of the cost

reporting period? If yes, enter the date of the change in column 2. (see instructions)

N 1.00

Y/N Date V/I

1.00 2.00 3.00

2.00 Has the provider terminated participation in the Medicare Program? If

yes, enter in column 2 the date of termination and in column 3, "V" for

voluntary or "I" for involuntary.

N 2.00

3.00 Is the provider involved in business transactions, including management

contracts, with individuals or entities (e.g., chain home offices, drug

or medical supply companies) that are related to the provider or its

officers, medical staff, management personnel, or members of the board

of directors through ownership, control, or family and other similar

relationships? (see instructions)

Y 3.00

Y/N Type Date

1.00 2.00 3.00

Financial Data and Reports

4.00 Column 1: Were the financial statements prepared by a Certified Public

Accountant? Column 2: If yes, enter "A" for Audited, "C" for Compiled,

or "R" for Reviewed. Submit complete copy or enter date available in

column 3. (see instructions) If no, see instructions.

Y A 4.00

5.00 Are the cost report total expenses and total revenues different from

those on the filed financial statements? If yes, submit reconciliation.

Y 5.00

Y/N Legal Oper.

1.00 2.00

Approved Educational Activities

6.00 Column 1: Are costs claimed for nursing school? Column 2: If yes, is the provider is

the legal operator of the program?

N 6.00

7.00 Are costs claimed for Allied Health Programs? If "Y" see instructions. Y 7.00

8.00 Were nursing school and/or allied health programs approved and/or renewed during the

cost reporting period? If yes, see instructions.

Y 8.00

9.00 Are costs claimed for Intern-Resident programs claimed on the current cost report? If

yes, see instructions.

Y 9.00

10.00 Was an Intern-Resident program been initiated or renewed in the current cost reporting

period? If yes, see instructions.

Y 10.00

11.00 Are GME cost directly assigned to cost centers other than I & R in an Approved

Teaching Program on Worksheet A? If yes, see instructions.

N 11.00

Y/N

1.00

Bad Debts

12.00 Is the provider seeking reimbursement for bad debts? If yes, see instructions. Y 12.00

13.00 If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting

period? If yes, submit copy.

N 13.00

14.00 If line 12 is yes, were patient deductibles and/or co-payments waived? If yes, see instructions. N 14.00

Bed Complement

15.00 Did total beds available change from the prior cost reporting period? If yes, see instructions. Y 15.00

Part A

Description Y/N Date

0 1.00 2.00

PS&R Data

16.00 Was the cost report prepared using the PS&R

Report only? If either column 1 or 3 is yes,

enter the paid-through date of the PS&R

Report used in columns 2 and 4 .(see

instructions)

N 16.00


Report for totals and the provider's records

for allocation? If either column 1 or 3 is

yes, enter the paid-through date in columns

2 and 4. (see instructions)

Y 04/13/2012 17.00

18.00 If line 16 or 17 is yes, were adjustments

made to PS&R Report data for additional

claims that have been billed but are not

included on the PS&R Report used to file

this cost report? If yes, see instructions.

N 18.00


made to PS&R Report data for corrections of

other PS&R Report information? If yes, see

instructions.

N 19.00


made to PS&R Report data for Other? Describe

the other adjustments:

N 20.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Part A

Description Y/N Date

0 1.00 2.00

21.00 Was the cost report prepared only using the

provider's records? If yes, see

instructions.

N 21.00

1.00

COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)

Capital Related Cost

22.00 Have assets been relifed for Medicare purposes? If yes, see instructions 22.00

23.00 Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost

reporting period? If yes, see instructions.

23.00

24.00 Were new leases and/or amendments to existing leases entered into during this cost reporting period?

If yes, see instructions

24.00

25.00 Have there been new capitalized leases entered into during the cost reporting period? If yes, see

instructions.

25.00

26.00 Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see

instructions.

26.00

27.00 Has the provider's capitalization policy changed during the cost reporting period? If yes, submit

copy.

27.00

Interest Expense

28.00 Were new loans, mortgage agreements or letters of credit entered into during the cost reporting

period? If yes, see instructions.

28.00

29.00 Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund)

treated as a funded depreciation account? If yes, see instructions

29.00

30.00 Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see

instructions.

30.00

31.00 Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see

instructions.

31.00

Purchased Services

32.00 Have changes or new agreements occurred in patient care services furnished through contractual

arrangements with suppliers of services? If yes, see instructions.

32.00

33.00 If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding? If

no, see instructions.

33.00

Provider-Based Physicians

34.00 Are services furnished at the provider facility under an arrangement with provider-based physicians?

If yes, see instructions.

34.00

35.00 If line 34 is yes, were there new agreements or amended existing agreements with the provider-based

physicians during the cost reporting period? If yes, see instructions.

35.00

Y/N Date

1.00 2.00

Home Office Costs

36.00 Were home office costs claimed on the cost report? 36.00

37.00 If line 36 is yes, has a home office cost statement been prepared by the home office?

If yes, see instructions.

37.00

38.00 If line 36 is yes , was the fiscal year end of the home office different from that of

the provider? If yes, enter in column 2 the fiscal year end of the home office.

38.00

39.00 If line 36 is yes, did the provider render services to other chain components? If yes,

see instructions.

39.00

40.00 If line 36 is yes, did the provider render services to the home office? If yes, see

instructions.

40.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-2

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Part B

Y/N Date

3.00 4.00

PS&R Data


Report only? If either column 1 or 3 is yes,

enter the paid-through date of the PS&R

Report used in columns 2 and 4 .(see

instructions)

N 16.00


Report for totals and the provider's records

for allocation? If either column 1 or 3 is

yes, enter the paid-through date in columns

2 and 4. (see instructions)

Y 04/13/2012 17.00


made to PS&R Report data for additional

claims that have been billed but are not

included on the PS&R Report used to file

this cost report? If yes, see instructions.

N 18.00


made to PS&R Report data for corrections of

other PS&R Report information? If yes, see

instructions.

N 19.00


made to PS&R Report data for Other? Describe

the other adjustments:

N 20.00

21.00 Was the cost report prepared only using the

provider's records? If yes, see

instructions.

N 21.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA

Cost Center Description Worksheet A

Line Number

No. of Beds Bed Days

Available

CAH Hours

1.00 2.00 3.00 4.00

1.00 Hospital Adults & Peds. (columns 5, 6, 7 and

8 exclude Swing Bed, Observation Bed and

Hospice days)

30.00 475 173,375 0.00 1.00

2.00 HMO 2.00

3.00 HMO IPF 3.00

4.00 HMO IRF 4.00

5.00 Hospital Adults & Peds. Swing Bed SNF 5.00

6.00 Hospital Adults & Peds. Swing Bed NF 6.00

7.00 Total Adults and Peds. (exclude observation

beds) (see instructions)

475 173,375 0.00 7.00

8.00 INTENSIVE CARE UNIT 31.00 88 32,120 0.00 8.00

8.01 NEONATAL INTENSIVE CARE UNIT 31.01 28 10,220 0.00 8.01

9.00 CORONARY CARE UNIT 32.00 0 0 0.00 9.00

10.00 BURN INTENSIVE CARE UNIT 33.00 0 0 0.00 10.00

11.00 SURGICAL INTENSIVE CARE UNIT 34.00 0 0 0.00 11.00

12.00 OTHER SPECIAL CARE (SPECIFY) 12.00

13.00 NURSERY 43.00 13.00

14.00 Total (see instructions) 591 215,715 0.00 14.00

15.00 CAH visits 15.00

16.00 SUBPROVIDER - IPF 40.00 46 16,790 16.00

17.00 SUBPROVIDER - IRF 41.00 37 13,505 17.00

18.00 SUBPROVIDER 42.00 0 0 18.00

19.00 SKILLED NURSING FACILITY 19.00

20.00 NURSING FACILITY 20.00

21.00 OTHER LONG TERM CARE 21.00

22.00 HOME HEALTH AGENCY 22.00

23.00 AMBULATORY SURGICAL CENTER (D.P.) 23.00

24.00 HOSPICE 24.00

25.00 CMHC - CMHC 25.00

25.10 CMHC - CORF 99.10 25.10

26.00 RURAL HEALTH CLINIC 88.00 26.00

26.25 FEDERALLY QUALIFIED HEALTH CENTER 89.00 26.25

27.00 Total (sum of lines 14-26) 674 27.00

28.00 Observation Bed Days 28.00

28.01 SUBPROVIDER - IPF 40.00 28.01

28.02 SUBPROVIDER - IRF 41.00 28.02

28.03 SUBPROVIDER 42.00 28.03

29.00 Ambulance Trips 29.00

30.00 Employee discount days (see instruction) 30.00

31.00 Employee discount days - IRF 31.00

32.00 Labor & delivery days (see instructions) 32.00

33.00 LTCH non-covered days 33.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


I/P Days / O/P Visits / Trips

Cost Center Description Title V Title XVIII Title XIX Total All

Patients

5.00 6.00 7.00 8.00



Hospice days)

0 57,821 27,589 143,199 1.00

2.00 HMO 10,618 9,367 2.00

3.00 HMO IPF 0 0 3.00

4.00 HMO IRF 0 0 4.00

5.00 Hospital Adults & Peds. Swing Bed SNF 0 0 0 0 5.00

6.00 Hospital Adults & Peds. Swing Bed NF 0 0 0 6.00



0 57,821 27,589 143,199 7.00

8.00 INTENSIVE CARE UNIT 0 11,908 5,261 28,759 8.00

8.01 NEONATAL INTENSIVE CARE UNIT 0 0 5,538 10,910 8.01

9.00 CORONARY CARE UNIT 0 0 0 0 9.00

10.00 BURN INTENSIVE CARE UNIT 0 0 0 0 10.00

11.00 SURGICAL INTENSIVE CARE UNIT 0 0 0 0 11.00


13.00 NURSERY 0 5,673 11,986 13.00

14.00 Total (see instructions) 0 69,729 44,061 194,854 14.00

15.00 CAH visits 0 0 0 0 15.00

16.00 SUBPROVIDER - IPF 0 4,494 893 9,588 16.00

17.00 SUBPROVIDER - IRF 0 7,087 589 12,536 17.00

18.00 SUBPROVIDER 0 0 0 0 18.00






24.00 HOSPICE 24.00

25.00 CMHC - CMHC 25.00

25.10 CMHC - CORF 0 0 0 0 25.10

26.00 RURAL HEALTH CLINIC 0 0 0 0 26.00

26.25 FEDERALLY QUALIFIED HEALTH CENTER 0 0 0 0 26.25

27.00 Total (sum of lines 14-26) 27.00

28.00 Observation Bed Days 0 929 4,173 28.00

28.01 SUBPROVIDER - IPF 0 28.01

28.02 SUBPROVIDER - IRF 0 28.02

28.03 SUBPROVIDER 0 28.03

29.00 Ambulance Trips 0 29.00

30.00 Employee discount days (see instruction) 0 30.00

31.00 Employee discount days - IRF 0 31.00

32.00 Labor & delivery days (see instructions) 757 1,433 32.00

33.00 LTCH non-covered days 0 33.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Full Time Equivalents Discharges

Cost Center Description Total Interns

& Residents

Employees On

Payroll

Nonpaid

Workers

Title V Title XVIII

9.00 10.00 11.00 12.00 13.00



Hospice days)

0 13,132 1.00

2.00 HMO 0 2.00

3.00 HMO IPF 3.00

4.00 HMO IRF 4.00





7.00

8.00 INTENSIVE CARE UNIT 8.00

8.01 NEONATAL INTENSIVE CARE UNIT 8.01

9.00 CORONARY CARE UNIT 9.00

10.00 BURN INTENSIVE CARE UNIT 10.00

11.00 SURGICAL INTENSIVE CARE UNIT 11.00


13.00 NURSERY 13.00

14.00 Total (see instructions) 214.23 4,554.00 0.00 0 13,132 14.00


16.00 SUBPROVIDER - IPF 0.00 58.00 0.00 0 547 16.00

17.00 SUBPROVIDER - IRF 0.00 82.00 0.00 0 513 17.00

18.00 SUBPROVIDER 0.00 0.00 0.00 0 0 18.00






24.00 HOSPICE 24.00

25.00 CMHC - CMHC 25.00

25.10 CMHC - CORF 0.00 0.00 0.00 25.10

26.00 RURAL HEALTH CLINIC 0.00 0.00 0.00 26.00

26.25 FEDERALLY QUALIFIED HEALTH CENTER 0.00 0.00 0.00 26.25

27.00 Total (sum of lines 14-26) 214.23 4,694.00 0.00 27.00


28.01 SUBPROVIDER - IPF 28.01

28.02 SUBPROVIDER - IRF 28.02

28.03 SUBPROVIDER 28.03







MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Discharges

Cost Center Description Title XIX Total All

Patients

14.00 15.00



Hospice days)

7,030 38,403 1.00

2.00 HMO 2.00

3.00 HMO IPF 3.00

4.00 HMO IRF 4.00





7.00







13.00 NURSERY 13.00

14.00 Total (see instructions) 7,030 38,403 14.00


16.00 SUBPROVIDER - IPF 171 1,453 16.00

17.00 SUBPROVIDER - IRF 33 911 17.00

18.00 SUBPROVIDER 0 0 18.00






24.00 HOSPICE 24.00

25.00 CMHC - CMHC 25.00

25.10 CMHC - CORF 25.10

26.00 RURAL HEALTH CLINIC 26.00

26.25 FEDERALLY QUALIFIED HEALTH CENTER 26.25

27.00 Total (sum of lines 14-26) 27.00











MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL WAGE INDEX INFORMATION

Worksheet A

Line Number

Amount

Reported

Reclassificati

on of Salaries

(from

Worksheet A-6)

Adjusted

Salaries

(col.2 ± col.

3)

Paid Hours

Related to

Salaries in

col. 4

1.00 2.00 3.00 4.00 5.00

PART II - WAGE DATA

SALARIES

1.00 Total salaries (see instructions) 200.00 312,823,235 0 312,823,235 9,768,172.00 1.00

2.00 Non-physician anesthetist Part A 0 0 0 0.00 2.00

3.00 Non-physician anesthetist Part B 0 0 0 0.00 3.00

4.00 Physician-Part A 0 0 0 0.00 4.00

4.01 Physicians - Part A - direct teaching 0 0 0 0.00 4.01

5.00 Physician-Part B 0 0 0 0.00 5.00

6.00 Non-physician-Part B 0 0 0 0.00 6.00

7.00 Interns & residents (in an approved program) 21.00 14,498,690 0 14,498,690 307,944.00 7.00

7.01 Contracted interns and residents (in

approved programs)

0 0 0 0.00 7.01

8.00 Home office personnel 0 0 0 0.00 8.00

9.00 SNF 44.00 0 0 0 0.00 9.00

10.00 Excluded area salaries (see instructions) 11,915,548 967,772 12,883,320 391,248.00 10.00

OTHER WAGES & RELATED COSTS

11.00 Contract labor (see instructions) 2,280,470 0 2,280,470 48,432.00 11.00

12.00 Management and administrative services 0 0 0 0.00 12.00

13.00 Contract labor: physician-Part A 9,766,614 0 9,766,614 71,141.00 13.00

14.00 Home office salaries & wage-related costs 46,972,335 0 46,972,335 1,006,345.00 14.00

15.00 Home office: physician Part A 0 0 0 0.00 15.00

16.00 Teaching physician salaries (see

instructions)

0 0 0 0.00 16.00

WAGE-RELATED COSTS

17.00 Wage-related costs (core) Wkst S-3, Part IV

line 24

75,584,998 0 75,584,998 17.00

18.00 Wage-related costs (other)Wkst S-3, Part IV

line 25

0 0 0 18.00

19.00 Excluded areas 3,406,837 0 3,406,837 19.00

20.00 Non-physician anesthetist Part A 0 0 0 20.00

21.00 Non-physician anesthetist Part B 0 0 0 21.00

22.00 Physician Part A 0 0 0 22.00

23.00 Physician Part B 0 0 0 23.00

24.00 Wage-related costs (RHC/FQHC) 0 0 0 24.00

25.00 Interns & residents (in an approved program) 2,934,619 0 2,934,619 25.00

OVERHEAD COSTS - DIRECT SALARIES

26.00 Employee Benefits 4.00 3,984,901 0 3,984,901 29,016.00 26.00

27.00 Administrative & General 5.00 29,889,392 -278,375 29,611,017 965,432.00 27.00

28.00 Administrative & General under contract (see

inst.)

2,310,793 0 2,310,793 20,986.00 28.00

29.00 Maintenance & Repairs 6.00 3,278,960 0 3,278,960 121,202.00 29.00

30.00 Operation of Plant 7.00 0 0 0 0.00 30.00

31.00 Laundry & Linen Service 8.00 0 0 0 0.00 31.00

32.00 Housekeeping 9.00 6,489,386 0 6,489,386 433,472.00 32.00

33.00 Housekeeping under contract (see

instructions)

696,451 0 696,451 50,651.00 33.00

34.00 Dietary 10.00 4,943,528 0 4,943,528 297,170.00 34.00

35.00 Dietary under contract (see instructions) 0 0 0 0.00 35.00

36.00 Cafeteria 11.00 0 0 0 0.00 36.00

37.00 Maintenance of Personnel 12.00 0 0 0 0.00 37.00

38.00 Nursing Administration 13.00 2,341,622 0 2,341,622 54,226.00 38.00

39.00 Central Services and Supply 14.00 0 0 0 0.00 39.00

40.00 Pharmacy 15.00 9,041,551 -172,142 8,869,409 206,773.00 40.00

41.00 Medical Records & Medical Records Library 16.00 3,227,076 0 3,227,076 135,678.00 41.00

42.00 Social Service 17.00 1,718,950 0 1,718,950 58,344.00 42.00

43.00 Other General Service 18.00 0 0 0 0.00 43.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Average Hourly

Wage (col. 4 ÷

col. 5)

6.00

PART II - WAGE DATA

SALARIES

1.00 Total salaries (see instructions) 32.02 1.00

2.00 Non-physician anesthetist Part A 0.00 2.00

3.00 Non-physician anesthetist Part B 0.00 3.00

4.00 Physician-Part A 0.00 4.00

4.01 Physicians - Part A - direct teaching 0.00 4.01

5.00 Physician-Part B 0.00 5.00

6.00 Non-physician-Part B 0.00 6.00

7.00 Interns & residents (in an approved program) 47.08 7.00

7.01 Contracted interns and residents (in

approved programs)

0.00 7.01

8.00 Home office personnel 0.00 8.00

9.00 SNF 0.00 9.00

10.00 Excluded area salaries (see instructions) 32.93 10.00

OTHER WAGES & RELATED COSTS

11.00 Contract labor (see instructions) 47.09 11.00

12.00 Management and administrative services 0.00 12.00

13.00 Contract labor: physician-Part A 137.29 13.00

14.00 Home office salaries & wage-related costs 46.68 14.00

15.00 Home office: physician Part A 0.00 15.00

16.00 Teaching physician salaries (see

instructions)

0.00 16.00

WAGE-RELATED COSTS

17.00 Wage-related costs (core) Wkst S-3, Part IV

line 24

17.00

18.00 Wage-related costs (other)Wkst S-3, Part IV

line 25

18.00

19.00 Excluded areas 19.00

20.00 Non-physician anesthetist Part A 20.00

21.00 Non-physician anesthetist Part B 21.00

22.00 Physician Part A 22.00

23.00 Physician Part B 23.00

24.00 Wage-related costs (RHC/FQHC) 24.00

25.00 Interns & residents (in an approved program) 25.00

OVERHEAD COSTS - DIRECT SALARIES

26.00 Employee Benefits 137.33 26.00

27.00 Administrative & General 30.67 27.00

28.00 Administrative & General under contract (see

inst.)

110.11 28.00

29.00 Maintenance & Repairs 27.05 29.00

30.00 Operation of Plant 0.00 30.00

31.00 Laundry & Linen Service 0.00 31.00

32.00 Housekeeping 14.97 32.00

33.00 Housekeeping under contract (see

instructions)

13.75 33.00

34.00 Dietary 16.64 34.00

35.00 Dietary under contract (see instructions) 0.00 35.00

36.00 Cafeteria 0.00 36.00

37.00 Maintenance of Personnel 0.00 37.00

38.00 Nursing Administration 43.18 38.00

39.00 Central Services and Supply 0.00 39.00

40.00 Pharmacy 42.89 40.00

41.00 Medical Records & Medical Records Library 23.78 41.00

42.00 Social Service 29.46 42.00

43.00 Other General Service 0.00 43.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Worksheet A

Line Number

Amount

Reported

Reclassificati

on of Salaries

(from

Worksheet A-6)

Adjusted

Salaries

(col.2 ± col.

3)

Paid Hours

Related to

Salaries in

col. 4

1.00 2.00 3.00 4.00 5.00

PART III - HOSPITAL WAGE INDEX SUMMARY

1.00 Net salaries (see instructions) 301,331,789 0 301,331,789 9,531,865.00 1.00

2.00 Excluded area salaries (see instructions) 11,915,548 967,772 12,883,320 391,248.00 2.00

3.00 Subtotal salaries (line 1 minus line 2) 289,416,241 -967,772 288,448,469 9,140,617.00 3.00

4.00 Subtotal other wages & related costs (see

inst.)

59,019,419 0 59,019,419 1,125,918.00 4.00

5.00 Subtotal wage-related costs (see inst.) 75,584,998 0 75,584,998 0.00 5.00

6.00 Total (sum of lines 3 thru 5) 424,020,658 -967,772 423,052,886 10,266,535.00 6.00

7.00 Total overhead cost (see instructions) 67,922,610 -450,517 67,472,093 2,372,950.00 7.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Average Hourly

Wage (col. 4 ÷

col. 5)

6.00

PART III - HOSPITAL WAGE INDEX SUMMARY

1.00 Net salaries (see instructions) 31.61 1.00

2.00 Excluded area salaries (see instructions) 32.93 2.00

3.00 Subtotal salaries (line 1 minus line 2) 31.56 3.00

4.00 Subtotal other wages & related costs (see

inst.)

52.42 4.00

5.00 Subtotal wage-related costs (see inst.) 26.20 5.00

6.00 Total (sum of lines 3 thru 5) 41.21 6.00

7.00 Total overhead cost (see instructions) 28.43 7.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL WAGE RELATED COSTS

Amount

Reported

1.00

PART IV - WAGE RELATED COSTS

Part A - Core List

RETIREMENT COST

1.00 401K Employer Contributions 6,194,598 1.00

2.00 Tax Sheltered Annuity (TSA) Employer Contribution 0 2.00

3.00 Qualified and Non-Qualified Pension Plan Cost 4,255,183 3.00

4.00 Prior Year Pension Service Cost 0 4.00

PLAN ADMINISTRATIVE COSTS (Paid to External Organization)

5.00 401K/TSA Plan Administration fees 0 5.00

6.00 Legal/Accounting/Management Fees-Pension Plan 744,550 6.00

7.00 Employee Managed Care Program Administration Fees 0 7.00

HEALTH AND INSURANCE COST

8.00 Health Insurance (Purchased or Self Funded) 29,037,346 8.00

9.00 Prescription Drug Plan 6,284,002 9.00

10.00 Dental, Hearing and Vision Plan 1,439,032 10.00

11.00 Life Insurance (If employee is owner or beneficiary) 406,655 11.00

12.00 Accident Insurance (If employee is owner or beneficiary) 0 12.00

13.00 Disability Insurance (If employee is owner or beneficiary) 2,635,555 13.00

14.00 Long-Term Care Insurance (If employee is owner or beneficiary) 0 14.00

15.00 'Workers' Compensation Insurance 5,618,200 15.00

16.00 Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106.

Non cumulative portion)

0 16.00

TAXES

17.00 FICA-Employers Portion Only 22,040,281 17.00

18.00 Medicare Taxes - Employers Portion Only 0 18.00

19.00 Unemployment Insurance 463,849 19.00

20.00 State or Federal Unemployment Taxes 0 20.00

OTHER

21.00 Executive Deferred Compensation 713,522 21.00

22.00 Day Care Cost and Allowances -6,341,455 22.00

23.00 Tuition Reimbursement 2,093,680 23.00

24.00 Total Wage Related cost (Sum of lines 1 -23) 75,584,998 24.00

Part B - Other than Core Related Cost

25.00 OTHER WAGE RELATED COSTS (SPECIFY) 0 25.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-3

Part V

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL CONTRACT LABOR AND BENEFIT COST

Cost Center Description Contract Labor Benefit Cost

1.00 2.00

PART V - Contract Labor and Benefit Cost

Hospital and Hospital-Based Component Identification:

1.00 Total facility's contract labor and benefit cost 2,280,470 81,926,453 1.00

2.00 Hospital 2,280,470 79,370,518 2.00

3.00 Subprovider - IPF 0 1,117,926 3.00

4.00 Subprovider - IRF 0 1,438,009 4.00

5.00 Subprovider - (Other) 0 0 5.00

6.00 Swing Beds - SNF 0 0 6.00

7.00 Swing Beds - NF 0 0 7.00

8.00 Hospital-Based SNF 8.00

9.00 Hospital-Based NF 9.00

10.00 Hospital-Based OLTC 10.00

11.00 Hospital-Based HHA 11.00

12.00 Separately Certified ASC 12.00

13.00 Hospital-Based Hospice 13.00

14.00 Hospital-Based Health Clinic RHC 0 0 14.00

15.00 Hospital-Based Health Clinic FQHC 0 0 15.00

16.00 Hospital-Based-CMHC 16.00

16.10 Hospital-Based-CMHC 10 0 0 16.10

17.00 Renal Dialysis 0 0 17.00

18.00 0 0 18.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet S-10

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208HOSPITAL UNCOMPENSATED AND INDIGENT CARE DATA

1.00

Uncompensated and indigent care cost computation

1.00 Cost to charge ratio (Worksheet C, Part I line 200 column 3 divided by line 200 column 8) 0.294005 1.00

Medicaid (see instructions for each line)

2.00 Net revenue from Medicaid 105,403,329 2.00

3.00 Did you receive DSH or supplemental payments from Medicaid? Y 3.00

4.00 If line 3 is "yes", does line 2 include all DSH or supplemental payments from Medicaid? Y 4.00

5.00 If line 4 is "no", then enter DSH or supplemental payments from Medicaid 0 5.00

6.00 Medicaid charges 471,850,925 6.00

7.00 Medicaid cost (line 1 times line 6) 138,726,531 7.00

8.00 Difference between net revenue and costs for Medicaid program (line 7 minus sum of lines 2 and 5; if

< zero then enter zero)

33,323,202 8.00

State Children's Health Insurance Program (SCHIP) (see instructions for each line)

9.00 Net revenue from stand-alone SCHIP 0 9.00

10.00 Stand-alone SCHIP charges 0 10.00

11.00 Stand-alone SCHIP cost (line 1 times line 10) 0 11.00

12.00 Difference between net revenue and costs for stand-alone SCHIP (line 11 minus line 9; if < zero then

enter zero)

0 12.00

Other state or local government indigent care program (see instructions for each line)

13.00 Net revenue from state or local indigent care program (Not included on lines 2, 5 or 9) 0 13.00

14.00 Charges for patients covered under state or local indigent care program (Not included in lines 6 or

10)

0 14.00

15.00 State or local indigent care program cost (line 1 times line 14) 0 15.00

16.00 Difference between net revenue and costs for state or local indigent care program (line 15 minus line

13; if < zero then enter zero)

0 16.00

Uncompensated care (see instructions for each line)

17.00 Private grants, donations, or endowment income restricted to funding charity care 0 17.00

18.00 Government grants, appropriations or transfers for support of hospital operations 0 18.00

19.00 Total unreimbursed cost for Medicaid , SCHIP and state and local indigent care programs (sum of lines

8, 12 and 16)

33,323,202 19.00

Uninsured

patients

Insured

patients

Total (col. 1

+ col. 2)

1.00 2.00 3.00

20.00 Total initial obligation of patients approved for charity care (at full

charges excluding non-reimbursable cost centers) for the entire facility

43,621,821 7,144,090 50,765,911 20.00

21.00 Cost of initial obligation of patients approved for charity care (line 1

times line 20)

12,825,033 2,100,398 14,925,431 21.00

22.00 Partial payment by patients approved for charity care 52,938 113,140 166,078 22.00

23.00 Cost of charity care (line 21 minus line 22) 12,772,095 1,987,258 14,759,353 23.00

1.00

24.00 Does the amount in line 20 column 2 include charges for patient days beyond a length of stay limit

imposed on patients covered by Medicaid or other indigent care program?

N 24.00

25.00 If line 24 is "yes," charges for patient days beyond an indigent care program's length of stay limit 0 25.00

26.00 Total bad debt expense for the entire hospital complex (see instructions) 43,565,330 26.00

27.00 Medicare bad debts for the entire hospital complex (see instructions) 3,725,773 27.00

28.00 Non-Medicare and Non-Reimbursable bad debt expense (line 26 minus line 27) 39,839,557 28.00

29.00 Cost of non-Medicare bad debt expense (line 1 times line 28) 11,713,029 29.00

30.00 Cost of non-Medicare uncompensated care (line 23 column 3 plus line 29) 26,472,382 30.00

31.00 Total unreimbursed and uncompensated care cost (line 19 plus line 30) 59,795,584 31.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208RECLASSIFICATION AND ADJUSTMENTS OF TRIAL BALANCE OF EXPENSES

Cost Center Description Salaries Other Total (col. 1

+ col. 2)

Reclassificati

ons (See A-6)

Reclassified

Trial Balance

(col. 3 +-

col. 4)

1.00 2.00 3.00 4.00 5.00

GENERAL SERVICE COST CENTERS

1.00 NEW CAP REL COSTS-BLDG & FIXT 0 0 13,313,083 13,313,083 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 0 0 10,478,923 10,478,923 2.00

3.00 OTHER CAPITAL RELATED COSTS 0 0 0 0 3.00

4.00 EMPLOYEE BENEFITS 3,984,901 60,673,704 64,658,605 -78,528 64,580,077 4.00

5.01 NONPATIENT TELEPHONES 567,937 1,548,508 2,116,445 -27,238 2,089,207 5.01

5.02 DATA PROCESSING 1,722 23,690,930 23,692,652 -2,242 23,690,410 5.02

5.03 PURCHASING RECEIVING AND STORES 1,520,645 2,613,255 4,133,900 -248,175 3,885,725 5.03

5.04 ADMITTING 1,346,711 312,659 1,659,370 -12,936 1,646,434 5.04

5.05 ADMINISTRATIVE & GENERAL 5,858,235 9,052,041 14,910,276 -448,305 14,461,971 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 20,594,142 114,487,255 135,081,397 -12,484,868 122,596,529 5.06

6.00 MAINTENANCE & REPAIRS 3,278,960 18,479,632 21,758,592 -302,729 21,455,863 6.00

7.00 OPERATION OF PLANT 0 0 0 0 0 7.00

8.00 LAUNDRY & LINEN SERVICE 0 3,468,912 3,468,912 -220 3,468,692 8.00

9.00 HOUSEKEEPING 6,489,386 3,262,990 9,752,376 -22,663 9,729,713 9.00

10.00 DIETARY 4,943,528 5,065,286 10,008,814 -36,161 9,972,653 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 2,341,622 969,776 3,311,398 -314,836 2,996,562 13.00

15.00 PHARMACY 9,041,551 33,949,548 42,991,099 -34,167,634 8,823,465 15.00

16.00 MEDICAL RECORDS & LIBRARY 3,227,076 3,105,730 6,332,806 -12,732 6,320,074 16.00

17.00 SOCIAL SERVICE 1,718,950 322,400 2,041,350 0 2,041,350 17.00

19.00 NONPHYSICIAN ANESTHETISTS 0 0 0 0 0 19.00

21.00 I&R SERVICES-SALARY & FRINGES APPRVD 14,498,690 0 14,498,690 0 14,498,690 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 13,281,519 13,281,519 -4,499 13,277,020 22.00

23.00 PARAMEDIC 0 0 0 832,379 832,379 23.00

23.01 PASTORAL CARE 0 0 0 280,329 280,329 23.01

23.02 PHARMACY RESIDENCY 0 0 0 184,583 184,583 23.02

INPATIENT ROUTINE SERVICE COST CENTERS

30.00 ADULTS & PEDIATRICS 85,253,758 20,133,139 105,386,897 -8,425,455 96,961,442 30.00

31.00 INTENSIVE CARE UNIT 26,741,641 9,571,225 36,312,866 -4,122,123 32,190,743 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 9,601,900 2,785,076 12,386,976 -3,918,223 8,468,753 31.01

32.00 CORONARY CARE UNIT 0 0 0 0 0 32.00

33.00 BURN INTENSIVE CARE UNIT 0 0 0 0 0 33.00

34.00 SURGICAL INTENSIVE CARE UNIT 0 0 0 0 0 34.00

40.00 SUBPROVIDER - IPF 4,219,557 450,774 4,670,331 -49,758 4,620,573 40.00

41.00 SUBPROVIDER - IRF 5,446,459 1,316,983 6,763,442 -234,546 6,528,896 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 0 0 0 3,978,918 3,978,918 43.00

ANCILLARY SERVICE COST CENTERS

50.00 OPERATING ROOM 24,007,615 72,564,734 96,572,349 -61,218,646 35,353,703 50.00

51.00 RECOVERY ROOM 3,668,054 395,040 4,063,094 -15,310 4,047,784 51.00

52.00 DELIVERY ROOM & LABOR ROOM 6,711,206 2,600,008 9,311,214 -1,385,235 7,925,979 52.00

53.00 ANESTHESIOLOGY 771,361 1,972,771 2,744,132 -1,313,116 1,431,016 53.00

54.00 RADIOLOGY-DIAGNOSTIC 19,575,611 26,898,899 46,474,510 -18,007,963 28,466,547 54.00

57.00 CT SCAN 0 0 0 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 0 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0 0 0 0 0 59.00

60.00 LABORATORY 169,890 31,875,642 32,045,532 -7,955,542 24,089,990 60.00

60.01 BLOOD LABORATORY 0 4,916,357 4,916,357 -1,227,299 3,689,058 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 0 0 0 62.00

65.00 RESPIRATORY THERAPY 11,720,735 6,826,454 18,547,189 -5,236,967 13,310,222 65.00

66.00 PHYSICAL THERAPY 4,724,061 10,503,782 15,227,843 -11,084,297 4,143,546 66.00

67.00 OCCUPATIONAL THERAPY 4,383,174 717,139 5,100,313 -224,308 4,876,005 67.00

68.00 SPEECH PATHOLOGY 0 0 0 0 0 68.00

69.00 ELECTROCARDIOLOGY 3,232,390 1,174,578 4,406,968 -586,654 3,820,314 69.00

70.00 ELECTROENCEPHALOGRAPHY 362,026 89,190 451,216 -47,823 403,393 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 0 0 69,793,671 69,793,671 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 0 0 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 0 0 0 45,240,421 45,240,421 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 0 0 33,684,485 33,684,485 73.00

74.00 RENAL DIALYSIS 1,390,871 601,389 1,992,260 -387,515 1,604,745 74.00

76.00 DEV EVALUATION 1,040,372 151,245 1,191,617 -37,817 1,153,800 76.00

76.97 CARDIAC REHABILITATION 772,034 84,377 856,411 -15,176 841,235 76.97

OUTPATIENT SERVICE COST CENTERS

88.00 RURAL HEALTH CLINIC 0 0 0 0 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0 0 0 0 0 89.00

90.00 CLINIC 0 0 0 0 0 90.00

90.01 FAMILY PRACTICES 0 0 0 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 0 0 0 90.02

90.03 AMBULATORY CARE 1,493,655 655,227 2,148,882 -83,784 2,065,098 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 15,873,277 8,715,412 24,588,689 -3,727,531 20,861,158 91.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Salaries Other Total (col. 1

+ col. 2)

Reclassificati

ons (See A-6)

Reclassified

Trial Balance

(col. 3 +-

col. 4)

1.00 2.00 3.00 4.00 5.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 92.00

OTHER REIMBURSABLE COST CENTERS

99.10 CORF 0 0 0 0 0 99.10

SPECIAL PURPOSE COST CENTERS

109.00 PANCREAS ACQUISITION 0 0 0 0 0 109.00

110.00 INTESTINAL ACQUISITION 0 0 0 0 0 110.00

111.00 ISLET ACQUISITION 0 0 0 0 0 111.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 310,573,703 499,283,586 809,857,289 317,938 810,175,227 118.00

NONREIMBURSABLE COST CENTERS

190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 561 561 0 561 190.00

190.01 OTHER NONREIMB 2,249,532 2,565,691 4,815,223 -317,938 4,497,285 190.01

190.02 OTHER 0 0 0 0 0 190.02

200.00 TOTAL (SUM OF LINES 118-199) 312,823,235 501,849,838 814,673,073 0 814,673,073 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Adjustments

(See A-8)

Net Expenses

For Allocation

6.00 7.00


1.00 NEW CAP REL COSTS-BLDG & FIXT 1,806,753 15,119,836 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 3,687,458 14,166,381 2.00

3.00 OTHER CAPITAL RELATED COSTS 0 0 3.00

4.00 EMPLOYEE BENEFITS 8,496,719 73,076,796 4.00

5.01 NONPATIENT TELEPHONES -675 2,088,532 5.01

5.02 DATA PROCESSING -12,014,364 11,676,046 5.02

5.03 PURCHASING RECEIVING AND STORES -190 3,885,535 5.03

5.04 ADMITTING -507 1,645,927 5.04

5.05 ADMINISTRATIVE & GENERAL -81,462 14,380,509 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL -60,344,914 62,251,615 5.06

6.00 MAINTENANCE & REPAIRS -69,790 21,386,073 6.00

7.00 OPERATION OF PLANT 0 0 7.00

8.00 LAUNDRY & LINEN SERVICE 0 3,468,692 8.00

9.00 HOUSEKEEPING 0 9,729,713 9.00

10.00 DIETARY -2,964,927 7,007,726 10.00

11.00 CAFETERIA 0 0 11.00

13.00 NURSING ADMINISTRATION -44,129 2,952,433 13.00

15.00 PHARMACY -87,157 8,736,308 15.00

16.00 MEDICAL RECORDS & LIBRARY -18,471 6,301,603 16.00

17.00 SOCIAL SERVICE -231 2,041,119 17.00

19.00 NONPHYSICIAN ANESTHETISTS 0 0 19.00

21.00 I&R SERVICES-SALARY & FRINGES APPRVD -1,940,805 12,557,885 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD -468,397 12,808,623 22.00

23.00 PARAMEDIC -306,201 526,178 23.00

23.01 PASTORAL CARE -4,408 275,921 23.01

23.02 PHARMACY RESIDENCY 0 184,583 23.02


30.00 ADULTS & PEDIATRICS -2,542,568 94,418,874 30.00

31.00 INTENSIVE CARE UNIT -358,169 31,832,574 31.00

31.01 NEONATAL INTENSIVE CARE UNIT -356,028 8,112,725 31.01

32.00 CORONARY CARE UNIT 0 0 32.00

33.00 BURN INTENSIVE CARE UNIT 0 0 33.00

34.00 SURGICAL INTENSIVE CARE UNIT 0 0 34.00

40.00 SUBPROVIDER - IPF -173,430 4,447,143 40.00

41.00 SUBPROVIDER - IRF -468,201 6,060,695 41.00


43.00 NURSERY 0 3,978,918 43.00


50.00 OPERATING ROOM -1,070,454 34,283,249 50.00

51.00 RECOVERY ROOM 0 4,047,784 51.00

52.00 DELIVERY ROOM & LABOR ROOM -7,500 7,918,479 52.00

53.00 ANESTHESIOLOGY 0 1,431,016 53.00

54.00 RADIOLOGY-DIAGNOSTIC -225,347 28,241,200 54.00

57.00 CT SCAN 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0 0 59.00

60.00 LABORATORY -546,116 23,543,874 60.00

60.01 BLOOD LABORATORY 0 3,689,058 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 62.00

65.00 RESPIRATORY THERAPY -151,193 13,159,029 65.00

66.00 PHYSICAL THERAPY -217,883 3,925,663 66.00

67.00 OCCUPATIONAL THERAPY -4,399 4,871,606 67.00

68.00 SPEECH PATHOLOGY 0 0 68.00

69.00 ELECTROCARDIOLOGY -169 3,820,145 69.00

70.00 ELECTROENCEPHALOGRAPHY 0 403,393 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS -10,458 69,783,213 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 0 45,240,421 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 33,684,485 73.00

74.00 RENAL DIALYSIS 0 1,604,745 74.00

76.00 DEV EVALUATION -1,056 1,152,744 76.00

76.97 CARDIAC REHABILITATION -7,629 833,606 76.97


88.00 RURAL HEALTH CLINIC 0 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0 0 89.00

90.00 CLINIC 0 0 90.00

90.01 FAMILY PRACTICES 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 90.02

90.03 AMBULATORY CARE -179,716 1,885,382 90.03

90.04 OTHER 0 0 90.04

91.00 EMERGENCY -416,287 20,444,871 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Adjustments

(See A-8)

Net Expenses

For Allocation

6.00 7.00


99.10 CORF 0 0 99.10


109.00 PANCREAS ACQUISITION 0 0 109.00

110.00 INTESTINAL ACQUISITION 0 0 110.00

111.00 ISLET ACQUISITION 0 0 111.00

118.00 SUBTOTALS (SUM OF LINES 1-117) -71,092,301 739,082,926 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 561 190.00

190.01 OTHER NONREIMB 0 4,497,285 190.01

190.02 OTHER 0 0 190.02

200.00 TOTAL (SUM OF LINES 118-199) -71,092,301 743,580,772 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-6

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208RECLASSIFICATIONS

Increases

Cost Center Line # Salary Other

2.00 3.00 4.00 5.00

A - RECLASS IMPLANT COSTS

1.00 IMPL. DEV. CHARGED TO

PATIENT

72.00 0 45,240,421 1.00

TOTALS 0 45,240,421

B - RECLASS CHARGEABLE DRUGS

1.00 DRUGS CHARGED TO PATIENTS 73.00 0 33,684,485 1.00

TOTALS 0 33,684,485

C - RECLASS MEDICAL SUPPLIES COST

1.00 MEDICAL SUPPLIES CHARGED TO

PATIENTS

71.00 0 115,034,092 1.00

2.00 0.00 0 0 2.00

3.00 0.00 0 0 3.00

4.00 0.00 0 0 4.00

5.00 0.00 0 0 5.00

6.00 0.00 0 0 6.00

7.00 0.00 0 0 7.00

8.00 0.00 0 0 8.00

9.00 0.00 0 0 9.00

10.00 0.00 0 0 10.00

11.00 0.00 0 0 11.00

12.00 0.00 0 0 12.00

13.00 0.00 0 0 13.00

14.00 0.00 0 0 14.00

15.00 0.00 0 0 15.00

16.00 0.00 0 0 16.00

17.00 0.00 0 0 17.00

18.00 0.00 0 0 18.00

19.00 0.00 0 0 19.00

20.00 0.00 0 0 20.00

21.00 0.00 0 0 21.00

22.00 0.00 0 0 22.00

23.00 0.00 0 0 23.00

24.00 0.00 0 0 24.00

25.00 0.00 0 0 25.00

26.00 0.00 0 0 26.00

27.00 0.00 0 0 27.00

28.00 0.00 0 0 28.00

29.00 0.00 0 0 29.00

30.00 0.00 0 0 30.00

31.00 0.00 0 0 31.00

32.00 0.00 0 0 32.00

33.00 0.00 0 0 33.00

34.00 0.00 0 0 34.00

35.00 0.00 0 0 35.00

36.00 0.00 0 0 36.00

37.00 0.00 0 0 37.00

TOTALS 0 115,034,092

D - RECLASS HOMEBOUND NURSERY

1.00 NURSERY 43.00 2,220,615 250,416 1.00

TOTALS 2,220,615 250,416

E - RECLASS NURSERY

1.00 NURSERY 43.00 1,371,787 136,100 1.00

TOTALS 1,371,787 136,100

F - RECLASS PARAMEDICAL EDUCATION

1.00 PARAMEDIC 23.00 517,255 315,124 1.00

TOTALS 517,255 315,124

G - RECLASS PASTORAL CARE

1.00 PASTORAL CARE 23.01 278,375 1,954 1.00

TOTALS 278,375 1,954

H - RECLASS BUILDING DEPRECIATION

1.00 NEW CAP REL COSTS-BLDG &

FIXT

1.00 0 10,748,715 1.00

TOTALS 0 10,748,715

I - RECLASS EQUIPMENT DEPRECIATION

1.00 NEW CAP REL COSTS-MVBLE

EQUIP

2.00 0 10,007,050 1.00

2.00 0.00 0 0 2.00

3.00 0.00 0 0 3.00

4.00 0.00 0 0 4.00

5.00 0.00 0 0 5.00

6.00 0.00 0 0 6.00

7.00 0.00 0 0 7.00

8.00 0.00 0 0 8.00

9.00 0.00 0 0 9.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-6

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Increases

Cost Center Line # Salary Other

2.00 3.00 4.00 5.00

10.00 0.00 0 0 10.00

11.00 0.00 0 0 11.00

12.00 0.00 0 0 12.00

13.00 0.00 0 0 13.00

14.00 0.00 0 0 14.00

15.00 0.00 0 0 15.00

16.00 0.00 0 0 16.00

17.00 0.00 0 0 17.00

18.00 0.00 0 0 18.00

19.00 0.00 0 0 19.00

20.00 0.00 0 0 20.00

21.00 0.00 0 0 21.00

22.00 0.00 0 0 22.00

23.00 0.00 0 0 23.00

24.00 0.00 0 0 24.00

25.00 0.00 0 0 25.00

26.00 0.00 0 0 26.00

27.00 0.00 0 0 27.00

28.00 0.00 0 0 28.00

29.00 0.00 0 0 29.00

30.00 0.00 0 0 30.00

31.00 0.00 0 0 31.00

32.00 0.00 0 0 32.00

33.00 0.00 0 0 33.00

34.00 0.00 0 0 34.00

35.00 0.00 0 0 35.00

36.00 0.00 0 0 36.00

TOTALS 0 10,007,050

J - RECLASS LAND IMP. DEPRECIATION


FIXT

1.00 0 384,139 1.00

TOTALS 0 384,139

K - RECLASS LEASEHOLD IMP. DEPRECIATION


EQUIP

2.00 0 426,251 1.00

TOTALS 0 426,251

L - RECLASS CAPITAL INTEREST


FIXT

1.00 0 34,062 1.00

TOTALS 0 34,062

M - RECLASS REMEDIATION COST


FIXT

1.00 0 43,833 1.00

TOTALS 0 43,833

N - RECLASS VEHICLE DEPRECIATION


EQUIP

2.00 0 45,622 1.00

2.00 0.00 0 0 2.00

3.00 0.00 0 0 3.00

4.00 0.00 0 0 4.00

TOTALS 0 45,622

O - RECLASS BUILDING RENT


FIXT

1.00 0 2,102,334 1.00

2.00 0.00 0 0 2.00

3.00 0.00 0 0 3.00

4.00 0.00 0 0 4.00

5.00 0.00 0 0 5.00

6.00 0.00 0 0 6.00

7.00 0.00 0 0 7.00

8.00 0.00 0 0 8.00

9.00 0.00 0 0 9.00

10.00 0.00 0 0 10.00

TOTALS 0 2,102,334

P - RECLASS PHARMACY RESIDENCY

1.00 PHARMACY RESIDENCY 23.02 172,142 12,441 1.00

TOTALS 172,142 12,441

500.00 Grand Total: Increases 4,560,174 218,467,039 500.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-6

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Decreases

Cost Center Line # Salary Other Wkst. A-7 Ref.

6.00 7.00 8.00 9.00 10.00

A - RECLASS IMPLANT COSTS

1.00 MEDICAL SUPPLIES CHARGED TO

PATIENTS

71.00 0 45,240,421 0 1.00

TOTALS 0 45,240,421

B - RECLASS CHARGEABLE DRUGS

1.00 PHARMACY 15.00 0 33,684,485 0 1.00

TOTALS 0 33,684,485

C - RECLASS MEDICAL SUPPLIES COST

1.00 NONPATIENT TELEPHONES 5.01 0 73 0 1.00

2.00 DATA PROCESSING 5.02 0 41 0 2.00

3.00 PURCHASING RECEIVING AND

STORES

5.03 0 8,909 0 3.00

4.00 ADMITTING 5.04 0 1,390 0 4.00

5.00 ADMINISTRATIVE & GENERAL 5.05 0 938 0 5.00

6.00 OTHER ADMINISTRATIVE AND

GENERAL

5.06 0 13,225 0 6.00

7.00 MAINTENANCE & REPAIRS 6.00 0 11,107 0 7.00

8.00 LAUNDRY & LINEN SERVICE 8.00 0 220 0 8.00

9.00 HOUSEKEEPING 9.00 0 5,597 0 9.00

10.00 DIETARY 10.00 0 847 0 10.00

11.00 NURSING ADMINISTRATION 13.00 0 231,241 0 11.00

12.00 PHARMACY 15.00 0 93,557 0 12.00

13.00 MEDICAL RECORDS & LIBRARY 16.00 0 187 0 13.00

14.00 I&R SERVICES-OTHER PRGM

COSTS APPRVD

22.00 0 2,951 0 14.00

15.00 ADULTS & PEDIATRICS 30.00 0 6,158,186 0 15.00

16.00 INTENSIVE CARE UNIT 31.00 0 3,642,100 0 16.00

17.00 NEONATAL INTENSIVE CARE UNIT 31.01 0 1,092,288 0 17.00

18.00 SUBPROVIDER - IPF 40.00 0 44,259 0 18.00

19.00 SUBPROVIDER - IRF 41.00 0 226,671 0 19.00

20.00 OPERATING ROOM 50.00 0 57,984,573 0 20.00

21.00 RECOVERY ROOM 51.00 0 14,389 0 21.00

22.00 DELIVERY ROOM & LABOR ROOM 52.00 0 1,008,007 0 22.00

23.00 ANESTHESIOLOGY 53.00 0 1,162,340 0 23.00

24.00 RADIOLOGY-DIAGNOSTIC 54.00 0 15,238,205 0 24.00

25.00 LABORATORY 60.00 0 7,948,824 0 25.00

26.00 BLOOD LABORATORY 60.01 0 1,227,299 0 26.00

27.00 RESPIRATORY THERAPY 65.00 0 4,949,404 0 27.00

28.00 PHYSICAL THERAPY 66.00 0 10,814,555 0 28.00

29.00 OCCUPATIONAL THERAPY 67.00 0 191,713 0 29.00

30.00 ELECTROCARDIOLOGY 69.00 0 141,866 0 30.00

31.00 ELECTROENCEPHALOGRAPHY 70.00 0 6,401 0 31.00

32.00 RENAL DIALYSIS 74.00 0 323,881 0 32.00

33.00 DEV EVALUATION 76.00 0 31,002 0 33.00

34.00 CARDIAC REHABILITATION 76.97 0 11,104 0 34.00

35.00 AMBULATORY CARE 90.03 0 78,595 0 35.00

36.00 EMERGENCY 91.00 0 2,308,333 0 36.00

37.00 OTHER NONREIMB 190.01 0 59,814 0 37.00

TOTALS 0 115,034,092

D - RECLASS HOMEBOUND NURSERY

1.00 NEONATAL INTENSIVE CARE UNIT 31.01 2,220,615 250,416 0 1.00

TOTALS 2,220,615 250,416

E - RECLASS NURSERY

1.00 ADULTS & PEDIATRICS 30.00 1,371,787 136,100 0 1.00

TOTALS 1,371,787 136,100

F - RECLASS PARAMEDICAL EDUCATION

1.00 EMERGENCY 91.00 517,255 315,124 0 1.00

TOTALS 517,255 315,124

G - RECLASS PASTORAL CARE


GENERAL

5.06 278,375 1,954 0 1.00

TOTALS 278,375 1,954

H - RECLASS BUILDING DEPRECIATION


GENERAL

5.06 0 10,748,715 9 1.00

TOTALS 0 10,748,715

I - RECLASS EQUIPMENT DEPRECIATION

1.00 EMPLOYEE BENEFITS 4.00 0 1,089 9 1.00

2.00 NONPATIENT TELEPHONES 5.01 0 27,165 9 2.00

3.00 DATA PROCESSING 5.02 0 2,201 9 3.00

4.00 PURCHASING RECEIVING AND

STORES

5.03 0 239,266 9 4.00

5.00 ADMITTING 5.04 0 11,546 9 5.00

6.00 ADMINISTRATIVE & GENERAL 5.05 0 81,274 9 6.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-6

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Decreases

Cost Center Line # Salary Other Wkst. A-7 Ref.

6.00 7.00 8.00 9.00 10.00


GENERAL

5.06 0 395,259 9 7.00


9.00 HOUSEKEEPING 9.00 0 17,066 9 9.00

10.00 DIETARY 10.00 0 34,914 9 10.00

11.00 NURSING ADMINISTRATION 13.00 0 83,595 9 11.00

12.00 PHARMACY 15.00 0 140,046 9 12.00

13.00 MEDICAL RECORDS & LIBRARY 16.00 0 12,545 9 13.00

14.00 I&R SERVICES-OTHER PRGM

COSTS APPRVD

22.00 0 1,548 9 14.00

15.00 ADULTS & PEDIATRICS 30.00 0 657,196 9 15.00

16.00 INTENSIVE CARE UNIT 31.00 0 480,023 9 16.00

17.00 NEONATAL INTENSIVE CARE UNIT 31.01 0 354,904 9 17.00

18.00 SUBPROVIDER - IPF 40.00 0 5,499 9 18.00

19.00 SUBPROVIDER - IRF 41.00 0 7,875 9 19.00

20.00 OPERATING ROOM 50.00 0 2,966,859 9 20.00

21.00 RECOVERY ROOM 51.00 0 921 9 21.00

22.00 DELIVERY ROOM & LABOR ROOM 52.00 0 225,609 9 22.00

23.00 ANESTHESIOLOGY 53.00 0 150,776 9 23.00

24.00 RADIOLOGY-DIAGNOSTIC 54.00 0 2,126,628 9 24.00

25.00 LABORATORY 60.00 0 6,718 9 25.00

26.00 RESPIRATORY THERAPY 65.00 0 287,563 9 26.00

27.00 PHYSICAL THERAPY 66.00 0 30,805 9 27.00


29.00 ELECTROCARDIOLOGY 69.00 0 444,788 9 29.00

30.00 ELECTROENCEPHALOGRAPHY 70.00 0 41,422 9 30.00

31.00 RENAL DIALYSIS 74.00 0 63,634 9 31.00

32.00 DEV EVALUATION 76.00 0 6,815 9 32.00

33.00 CARDIAC REHABILITATION 76.97 0 4,072 9 33.00

34.00 AMBULATORY CARE 90.03 0 5,189 9 34.00

35.00 EMERGENCY 91.00 0 585,988 9 35.00

36.00 OTHER NONREIMB 190.01 0 258,124 9 36.00

TOTALS 0 10,007,050

J - RECLASS LAND IMP. DEPRECIATION


GENERAL

5.06 0 384,139 9 1.00

TOTALS 0 384,139

K - RECLASS LEASEHOLD IMP. DEPRECIATION


GENERAL

5.06 0 426,251 11 1.00

TOTALS 0 426,251

L - RECLASS CAPITAL INTEREST


GENERAL

5.06 0 34,062 11 1.00

TOTALS 0 34,062

M - RECLASS REMEDIATION COST


GENERAL

5.06 0 43,833 11 1.00

TOTALS 0 43,833

N - RECLASS VEHICLE DEPRECIATION


GENERAL

5.06 0 19,857 9 1.00

2.00 DIETARY 10.00 0 400 9 2.00


4.00 EMERGENCY 91.00 0 831 9 4.00

TOTALS 0 45,622

O - RECLASS BUILDING RENT

1.00 EMPLOYEE BENEFITS 4.00 0 77,439 10 1.00

2.00 ADMINISTRATIVE & GENERAL 5.05 0 366,093 10 2.00


GENERAL

5.06 0 139,198 10 3.00


5.00 PHARMACY 15.00 0 64,963 10 5.00

6.00 ADULTS & PEDIATRICS 30.00 0 102,186 10 6.00

7.00 OPERATING ROOM 50.00 0 267,214 10 7.00

8.00 RADIOLOGY-DIAGNOSTIC 54.00 0 643,130 10 8.00

9.00 PHYSICAL THERAPY 66.00 0 238,937 10 9.00

10.00 DELIVERY ROOM & LABOR ROOM 52.00 0 151,619 10 10.00

TOTALS 0 2,102,334

P - RECLASS PHARMACY RESIDENCY

1.00 PHARMACY 15.00 172,142 12,441 0 1.00

TOTALS 172,142 12,441

500.00 Grand Total: Decreases 4,560,174 218,467,039 500.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-7

Parts I-III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208RECONCILIATION OF CAPITAL COSTS CENTERS

Acquisitions

Beginning

Balances

Purchases Donation Total Disposals and

Retirements

1.00 2.00 3.00 4.00 5.00

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES

1.00 Land 4,097,884 3,355,000 0 3,355,000 0 1.00

2.00 Land Improvements 11,563,789 705,386 0 705,386 0 2.00

3.00 Buildings and Fixtures 279,214,484 8,649,377 0 8,649,377 0 3.00

4.00 Building Improvements 4,057,123 0 0 0 0 4.00

5.00 Fixed Equipment 155,237,229 16,881,469 0 16,881,469 2,390,689 5.00

6.00 Movable Equipment 509,963 0 0 0 0 6.00

7.00 HIT designated Assets 0 0 0 0 0 7.00

8.00 Subtotal (sum of lines 1-7) 454,680,472 29,591,232 0 29,591,232 2,390,689 8.00

9.00 Reconciling Items -4,321,217 -17,555,825 0 -17,555,825 0 9.00

10.00 Total (line 8 minus line 9) 459,001,689 47,147,057 0 47,147,057 2,390,689 10.00

SUMMARY OF CAPITAL

Cost Center Description Depreciation Lease Interest Insurance (see

instructions)

Taxes (see

instructions)

9.00 10.00 11.00 12.00 13.00

PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 and 2

1.00 NEW CAP REL COSTS-BLDG & FIXT 0 0 0 0 0 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 0 0 0 0 0 2.00

3.00 Total (sum of lines 1-2) 0 0 0 0 0 3.00

COMPUTATION OF RATIOS ALLOCATION OF

OTHER CAPITAL

Cost Center Description Gross Assets Capitalized

Leases

Gross Assets

for Ratio

(col. 1 - col.

2)

Ratio (see

instructions)

Insurance

1.00 2.00 3.00 4.00 5.00

PART III - RECONCILIATION OF CAPITAL COSTS CENTERS

1.00 NEW CAP REL COSTS-BLDG & FIXT 503,248,100 2,102,334 501,145,766 0.998983 0 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 509,963 0 509,963 0.001017 0 2.00

3.00 Total (sum of lines 1-2) 503,758,063 2,102,334 501,655,729 1.000000 0 3.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-7

Parts I-III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Ending Balance Fully

Depreciated

Assets

6.00 7.00

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES

1.00 Land 7,452,884 0 1.00

2.00 Land Improvements 12,269,175 3,598,884 2.00

3.00 Buildings and Fixtures 287,863,861 68,422,372 3.00

4.00 Building Improvements 4,057,123 170,409 4.00

5.00 Fixed Equipment 169,728,009 98,120,936 5.00

6.00 Movable Equipment 509,963 324,082 6.00

7.00 HIT designated Assets 0 0 7.00

8.00 Subtotal (sum of lines 1-7) 481,881,015 170,636,683 8.00

9.00 Reconciling Items -21,877,042 0 9.00

10.00 Total (line 8 minus line 9) 503,758,057 170,636,683 10.00

SUMMARY OF CAPITAL

Cost Center Description Other

Capital-Relate

d Costs (see

instructions)

Total (1) (sum

of cols. 9

through 14)

14.00 15.00

PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 and 2

1.00 NEW CAP REL COSTS-BLDG & FIXT 0 0 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 0 0 2.00

3.00 Total (sum of lines 1-2) 0 0 3.00

ALLOCATION OF OTHER CAPITAL SUMMARY OF

CAPITAL

Cost Center Description Taxes Other

Capital-Relate

d Costs

Total (sum of

cols. 5

through 7)

Depreciation Lease

6.00 7.00 8.00 9.00 10.00


1.00 NEW CAP REL COSTS-BLDG & FIXT 0 0 0 12,939,607 2,102,334 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 0 0 0 13,740,130 0 2.00

3.00 Total (sum of lines 1-2) 0 0 0 26,679,737 2,102,334 3.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-7

Parts I-III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


SUMMARY OF CAPITAL

Cost Center Description Interest Insurance (see

instructions)

Taxes (see

instructions)

Other

Capital-Relate

d Costs (see

instructions)

Total (2) (sum

of cols. 9

through 14)

11.00 12.00 13.00 14.00 15.00


1.00 NEW CAP REL COSTS-BLDG & FIXT 77,895 0 0 0 15,119,836 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 426,251 0 0 0 14,166,381 2.00

3.00 Total (sum of lines 1-2) 504,146 0 0 0 29,286,217 3.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208ADJUSTMENTS TO EXPENSES

Expense Classification on Worksheet A

To/From Which the Amount is to be Adjusted

Cost Center Description Basis/Code (2) Amount Cost Center Line #

1.00 2.00 3.00 4.00

1.00 Investment income - NEW CAP REL COSTS-BLDG &

FIXT (chapter 2)

0NEW CAP REL COSTS-BLDG &

FIXT

1.00 1.00

2.00 Investment income - NEW CAP REL COSTS-MVBLE

EQUIP (chapter 2)

0NEW CAP REL COSTS-MVBLE

EQUIP

2.00 2.00

3.00 Investment income - other (chapter 2) 0 0.00 3.00

4.00 Trade, quantity, and time discounts (chapter

8)

0 0.00 4.00

5.00 Refunds and rebates of expenses (chapter 8) 0 0.00 5.00

6.00 Rental of provider space by suppliers

(chapter 8)

0 0.00 6.00

7.00 Telephone services (pay stations excluded)

(chapter 21)

0 0.00 7.00

8.00 Television and radio service (chapter 21) 0 0.00 8.00

9.00 Parking lot (chapter 21) 0 0.00 9.00

10.00 Provider-based physician adjustment A-8-2 -6,095,749 10.00

11.00 Sale of scrap, waste, etc. (chapter 23) 0 0.00 11.00

12.00 Related organization transactions (chapter

10)

A-8-1 -11,320,307 12.00

13.00 Laundry and linen service 0 0.00 13.00

14.00 Cafeteria-employees and guests 0 0.00 14.00

15.00 Rental of quarters to employee and others 0 0.00 15.00

16.00 Sale of medical and surgical supplies to

other than patients

0 0.00 16.00

17.00 Sale of drugs to other than patients 0 0.00 17.00

18.00 Sale of medical records and abstracts A -17,859MEDICAL RECORDS & LIBRARY 16.00 18.00

19.00 Nursing school (tuition, fees, books, etc.) 0 0.00 19.00

20.00 Vending machines 0 0.00 20.00

21.00 Income from imposition of interest, finance

or penalty charges (chapter 21)

0 0.00 21.00

22.00 Interest expense on Medicare overpayments

and borrowings to repay Medicare

overpayments

0 0.00 22.00

23.00 Adjustment for respiratory therapy costs in

excess of limitation (chapter 14)

A-8-3 0RESPIRATORY THERAPY 65.00 23.00

24.00 Adjustment for physical therapy costs in


A-8-3 0PHYSICAL THERAPY 66.00 24.00

25.00 Utilization review - physicians'

compensation (chapter 21)

0*** Cost Center Deleted *** 114.00 25.00

26.00 Depreciation - NEW CAP REL COSTS-BLDG & FIXT A 423,123NEW CAP REL COSTS-BLDG &

FIXT

1.00 26.00

27.00 Depreciation - NEW CAP REL COSTS-MVBLE EQUIP A -132,540NEW CAP REL COSTS-MVBLE

EQUIP

2.00 27.00

28.00 Non-physician Anesthetist 0NONPHYSICIAN ANESTHETISTS 19.00 28.00

29.00 Physicians' assistant 0 0.00 29.00

30.00 Adjustment for occupational therapy costs in


A-8-3 0OCCUPATIONAL THERAPY 67.00 30.00

31.00 Adjustment for speech pathology costs in


A-8-3 0SPEECH PATHOLOGY 68.00 31.00

32.00 CAH HIT Adjustment for Depreciation and

Interest

A 0 0.00 32.00

33.00 REAL ESTATE TAX A 3,548OTHER ADMINISTRATIVE AND

GENERAL

5.06 33.00

33.01 REAL ESTATE TAX A -2,555RADIOLOGY-DIAGNOSTIC 54.00 33.01

34.00 MISC REV B -1,870EMPLOYEE BENEFITS 4.00 34.00

35.00 MISC REV B -675NONPATIENT TELEPHONES 5.01 35.00

38.00 MISC REV B -81,437ADMINISTRATIVE & GENERAL 5.05 38.00

39.00 MISC REV B -3,564,362OTHER ADMINISTRATIVE AND

GENERAL

5.06 39.00

41.00 MISC REV B -53,230MAINTENANCE & REPAIRS 6.00 41.00

42.00 MISC REV B -2,963,639DIETARY 10.00 42.00

43.00 MISC REV B -34,562NURSING ADMINISTRATION 13.00 43.00

44.00 MISC REV B -86,905PHARMACY 15.00 44.00

45.00 MISC REV B -406,634I&R SERVICES-OTHER PRGM

COSTS APPRVD

22.00 45.00

45.02 MISC REV B -306,201PARAMEDIC 23.00 45.02

45.03 MISC REV B -4,408PASTORAL CARE 23.01 45.03

45.04 MISC REV B -873,512ADULTS & PEDIATRICS 30.00 45.04

45.05 MISC REV B -28,827INTENSIVE CARE UNIT 31.00 45.05

45.07 MISC REV B -129,123NEONATAL INTENSIVE CARE UNIT 31.01 45.07

45.08 MISC REV B -43,941SUBPROVIDER - IRF 41.00 45.08


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Expense Classification on Worksheet A

To/From Which the Amount is to be Adjusted

Cost Center Description Basis/Code (2) Amount Cost Center Line #

1.00 2.00 3.00 4.00

45.09 MISC REV B -10,597OPERATING ROOM 50.00 45.09

45.10 MISC REV B -7,500DELIVERY ROOM & LABOR ROOM 52.00 45.10

45.11 MISC REV B -206,547RADIOLOGY-DIAGNOSTIC 54.00 45.11

45.12 MISC REV B -544,116LABORATORY 60.00 45.12

45.13 MISC REV B -960RESPIRATORY THERAPY 65.00 45.13

45.14 MISC REV B -64,310PHYSICAL THERAPY 66.00 45.14

45.15 MISC REV B -668OCCUPATIONAL THERAPY 67.00 45.15

45.16 MISC REV B -30ELECTROCARDIOLOGY 69.00 45.16

45.17 MISC REV B -10,458MEDICAL SUPPLIES CHARGED TO

PATIENTS

71.00 45.17

45.18 MISC REV B -7,629CARDIAC REHABILITATION 76.97 45.18

45.21 MISC REV B -156,377AMBULATORY CARE 90.03 45.21

45.22 MISC REV B -394,026EMERGENCY 91.00 45.22

45.24 NONALLOWABLE COSTS A -1,162EMPLOYEE BENEFITS 4.00 45.24

45.26 NONALLOWABLE COSTS A -190PURCHASING RECEIVING AND

STORES

5.03 45.26

45.28 NONALLOWABLE COSTS A -507ADMITTING 5.04 45.28

45.32 NONALLOWABLE COSTS A -25ADMINISTRATIVE & GENERAL 5.05 45.32

45.33 NONALLOWABLE COSTS A -5,492,739OTHER ADMINISTRATIVE AND

GENERAL

5.06 45.33

45.36 NONALLOWABLE COSTS A -16,560MAINTENANCE & REPAIRS 6.00 45.36

45.37 NONALLOWABLE COSTS A -1,288DIETARY 10.00 45.37

45.38 NONALLOWABLE COSTS A -9,567NURSING ADMINISTRATION 13.00 45.38

45.39 NONALLOWABLE COSTS A -252PHARMACY 15.00 45.39

45.40 NONALLOWABLE COSTS A -612MEDICAL RECORDS & LIBRARY 16.00 45.40

45.41 NONALLOWABLE COSTS A -231SOCIAL SERVICE 17.00 45.41

45.43 NONALLOWABLE COSTS A -61,763I&R SERVICES-OTHER PRGM

COSTS APPRVD

22.00 45.43

45.44 NONALLOWABLE COSTS A -31,838ADULTS & PEDIATRICS 30.00 45.44

45.45 NONALLOWABLE COSTS A -4,789INTENSIVE CARE UNIT 31.00 45.45

45.46 NONALLOWABLE COSTS A -1,245NEONATAL INTENSIVE CARE UNIT 31.01 45.46

45.49 NONALLOWABLE COSTS A -162SUBPROVIDER - IPF 40.00 45.49

45.50 NONALLOWABLE COSTS A -27,460SUBPROVIDER - IRF 41.00 45.50

45.51 NONALLOWABLE COSTS A -1,472OPERATING ROOM 50.00 45.51

45.52 NONALLOWABLE COSTS A -15,245RADIOLOGY-DIAGNOSTIC 54.00 45.52

45.53 NONALLOWABLE COSTS A -2,000LABORATORY 60.00 45.53

45.54 NONALLOWABLE COSTS A -139ELECTROCARDIOLOGY 69.00 45.54

45.57 NONALLOWABLE COSTS A -233RESPIRATORY THERAPY 65.00 45.57

45.58 NONALLOWABLE COSTS A -1,573PHYSICAL THERAPY 66.00 45.58

45.59 NONALLOWABLE COSTS A -3,731OCCUPATIONAL THERAPY 67.00 45.59

45.60 NONALLOWABLE COSTS A -1,056DEV EVALUATION 76.00 45.60

45.62 NONALLOWABLE COSTS A -664AMBULATORY CARE 90.03 45.62

45.63 NONALLOWABLE COSTS A -8,876EMERGENCY 91.00 45.63

45.64 NONREIMB PHYSICIAN FEES A -7,832,208OTHER ADMINISTRATIVE AND

GENERAL

5.06 45.64

45.65 ELIMINATE P/R AND MARKETING A -293,833OTHER ADMINISTRATIVE AND

GENERAL

5.06 45.65

45.66 INTEREST OFFSET A -4,836,829OTHER ADMINISTRATIVE AND

GENERAL

5.06 45.66

45.67 ELIMINATE MEDICAID ASSESSMENT A -25,322,472OTHER ADMINISTRATIVE AND

GENERAL

5.06 45.67

45.71 NONALLOWABLE AHA/IHA A 3,303OTHER ADMINISTRATIVE AND

GENERAL

5.06 45.71

50.00 TOTAL (sum of lines 1 thru 49) (Transfer to

Worksheet A, column 6, line 200.)

-71,092,301 50.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Wkst. A-7 Ref.

5.00

1.00 Investment income - NEW CAP REL COSTS-BLDG &

FIXT (chapter 2)

0 1.00

2.00 Investment income - NEW CAP REL COSTS-MVBLE

EQUIP (chapter 2)

0 2.00

3.00 Investment income - other (chapter 2) 0 3.00

4.00 Trade, quantity, and time discounts (chapter

8)

0 4.00

5.00 Refunds and rebates of expenses (chapter 8) 0 5.00

6.00 Rental of provider space by suppliers

(chapter 8)

0 6.00

7.00 Telephone services (pay stations excluded)

(chapter 21)

0 7.00

8.00 Television and radio service (chapter 21) 0 8.00

9.00 Parking lot (chapter 21) 0 9.00

10.00 Provider-based physician adjustment 0 10.00

11.00 Sale of scrap, waste, etc. (chapter 23) 0 11.00

12.00 Related organization transactions (chapter

10)

0 12.00

13.00 Laundry and linen service 0 13.00

14.00 Cafeteria-employees and guests 0 14.00

15.00 Rental of quarters to employee and others 0 15.00

16.00 Sale of medical and surgical supplies to

other than patients

0 16.00

17.00 Sale of drugs to other than patients 0 17.00

18.00 Sale of medical records and abstracts 0 18.00

19.00 Nursing school (tuition, fees, books, etc.) 0 19.00

20.00 Vending machines 0 20.00

21.00 Income from imposition of interest, finance

or penalty charges (chapter 21)

0 21.00

22.00 Interest expense on Medicare overpayments

and borrowings to repay Medicare

overpayments

0 22.00

23.00 Adjustment for respiratory therapy costs in


23.00

24.00 Adjustment for physical therapy costs in


24.00

25.00 Utilization review - physicians'

compensation (chapter 21)

25.00

26.00 Depreciation - NEW CAP REL COSTS-BLDG & FIXT 9 26.00

27.00 Depreciation - NEW CAP REL COSTS-MVBLE EQUIP 9 27.00

28.00 Non-physician Anesthetist 28.00

29.00 Physicians' assistant 0 29.00

30.00 Adjustment for occupational therapy costs in


30.00

31.00 Adjustment for speech pathology costs in


31.00

32.00 CAH HIT Adjustment for Depreciation and

Interest

0 32.00

33.00 REAL ESTATE TAX 0 33.00

33.01 REAL ESTATE TAX 0 33.01

34.00 MISC REV 0 34.00

35.00 MISC REV 0 35.00

38.00 MISC REV 0 38.00

39.00 MISC REV 0 39.00

41.00 MISC REV 0 41.00

42.00 MISC REV 0 42.00

43.00 MISC REV 0 43.00

44.00 MISC REV 0 44.00

45.00 MISC REV 0 45.00

45.02 MISC REV 0 45.02

45.03 MISC REV 0 45.03

45.04 MISC REV 0 45.04

45.05 MISC REV 0 45.05

45.07 MISC REV 0 45.07

45.08 MISC REV 0 45.08

45.09 MISC REV 0 45.09

45.10 MISC REV 0 45.10

45.11 MISC REV 0 45.11

45.12 MISC REV 0 45.12

45.13 MISC REV 0 45.13

45.14 MISC REV 0 45.14

45.15 MISC REV 0 45.15

45.16 MISC REV 0 45.16

45.17 MISC REV 0 45.17

45.18 MISC REV 0 45.18

45.21 MISC REV 0 45.21


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Wkst. A-7 Ref.

5.00

45.22 MISC REV 0 45.22

45.24 NONALLOWABLE COSTS 0 45.24



























45.64 NONREIMB PHYSICIAN FEES 0 45.64

45.65 ELIMINATE P/R AND MARKETING 0 45.65

45.66 INTEREST OFFSET 0 45.66

45.67 ELIMINATE MEDICAID ASSESSMENT 0 45.67

45.71 NONALLOWABLE AHA/IHA 0 45.71

50.00 TOTAL (sum of lines 1 thru 49) (Transfer to

Worksheet A, column 6, line 200.)

50.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME

OFFICE COSTS

Line No. Cost Center Expense Items

1.00 2.00 3.00

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED

HOME OFFICE COSTS:

1.00 4.00EMPLOYEE BENEFITS PERSONNEL 1.00

2.00 5.02DATA PROCESSING DATA PROCESSING 2.00

3.00 5.06OTHER ADMINISTRATIVE AND

GENERAL

A&G 3.00

4.00 1.00NEW CAP REL COSTS-BLDG &

FIXT

NEW CAP.-B&F 4.00

4.01 2.00NEW CAP REL COSTS-MVBLE

EQUIP

NEW CAP.-M.E. 4.01

4.02 0.00 4.02

4.03 0.00 4.03

5.00 TOTALS (sum of lines 1-4). Transfer column

6, line 5 to Worksheet A-8, column 2, line

12.

5.00

* The amounts on lines 1-4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as

appropriate. Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost

which has not been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

Symbol (1) Name Percentage of

Ownership

1.00 2.00 3.00

B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish

the information requested under Part B of this worksheet.

This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that

the costs applicable to services, facilities, and supplies furnished by organizations related to you by common ownership or

control represent reasonable costs as determined under section 1861 of the Social Security Act. If you do not provide all or any

part of the request information, the cost report is considered incomplete and not acceptable for purposes of claiming

reimbursement under title XVIII.

6.00 B 0.00 6.00

7.00 0.00 7.00

8.00 0.00 8.00

9.00 0.00 9.00

10.00 0.00 10.00

100.00 G. Other (financial or non-financial)

specify:

100.00

(1) Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.

B. Corporation, partnership, or other organization has financial interest in provider.

C. Provider has financial interest in corporation, partnership, or other organization.

D. Director, officer, administrator, or key person of provider or relative of such person has financial interest in related

organization.

E. Individual is director, officer, administrator, or key person of provider and related organization.

F. Director, officer, administrator, or key person of related organization or relative of such person has financial interest in

provider.


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME

OFFICE COSTS

Amount of

Allowable Cost

Amount

Included in

Wks. A, column

5

Net

Adjustments

(col. 4 minus

col. 5)*

Wkst. A-7 Ref.

4.00 5.00 6.00 7.00

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED

HOME OFFICE COSTS:

1.00 8,499,751 0 8,499,751 0 1.00

2.00 8,332,948 20,347,312 -12,014,364 0 2.00

3.00 14,740,424 27,749,746 -13,009,322 0 3.00

4.00 1,383,630 0 1,383,630 9 4.00

4.01 3,819,998 0 3,819,998 9 4.01

4.02 0 0 0 0 4.02

4.03 0 0 0 0 4.03

5.00 TOTALS (sum of lines 1-4). Transfer column

6, line 5 to Worksheet A-8, column 2, line

12.

36,776,751 48,097,058 -11,320,307 5.00

* The amounts on lines 1-4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as

appropriate. Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost

which has not been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

Related Organization(s) and/or Home Office

Name Percentage of

Ownership

Type of Business

4.00 5.00 6.00

B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish

the information requested under Part B of this worksheet.

This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that

the costs applicable to services, facilities, and supplies furnished by organizations related to you by common ownership or

control represent reasonable costs as determined under section 1861 of the Social Security Act. If you do not provide all or any

part of the request information, the cost report is considered incomplete and not acceptable for purposes of claiming

reimbursement under title XVIII.

6.00 ADVOCATE 100.00HEALTHCARE 6.00

7.00 0.00 7.00

8.00 0.00 8.00

9.00 0.00 9.00

10.00 0.00 10.00

100.00 G. Other (financial or non-financial)

specify:

100.00

(1) Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.

B. Corporation, partnership, or other organization has financial interest in provider.

C. Provider has financial interest in corporation, partnership, or other organization.

D. Director, officer, administrator, or key person of provider or relative of such person has financial interest in related

organization.

E. Individual is director, officer, administrator, or key person of provider and related organization.

F. Director, officer, administrator, or key person of related organization or relative of such person has financial interest in

provider.


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8-2

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208PROVIDER BASED PHYSICIAN ADJUSTMENT

Wkst. A Line # Cost Center/Physician

Identifier

Total

Remuneration

Professional

Component

1.00 2.00 3.00 4.00

1.00 21.00I&R SERVICES-SALARY &

FRINGES APPRVD

1,940,805 1,940,805 1.00

2.00 30.00ADULTS & PEDIATRICS 1,637,218 1,637,218 2.00

3.00 31.00INTENSIVE CARE UNIT 324,553 324,553 3.00

4.00 31.01NEONATAL INTENSIVE CARE UNIT 225,660 225,660 4.00

5.00 40.00SUBPROVIDER - IPF 173,268 173,268 5.00

6.00 41.00SUBPROVIDER - IRF 396,800 396,800 6.00

7.00 50.00OPERATING ROOM 1,058,385 1,058,385 7.00

8.00 54.00RADIOLOGY-DIAGNOSTIC 1,000 1,000 8.00

9.00 65.00RESPIRATORY THERAPY 150,000 150,000 9.00

10.00 66.00PHYSICAL THERAPY 152,000 152,000 10.00

11.00 90.03AMBULATORY CARE 22,675 22,675 11.00

12.00 91.00EMERGENCY 13,385 13,385 12.00

200.00 6,095,749 6,095,749 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8-2

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Provider

Component

RCE Amount Physician/Prov

ider Component

Hours

Unadjusted RCE

Limit

5 Percent of

Unadjusted RCE

Limit

5.00 6.00 7.00 8.00 9.00

1.00 0 177,200 0 0 0 1.00

2.00 0 177,200 0 0 0 2.00

3.00 0 177,200 0 0 0 3.00

4.00 0 177,200 0 0 0 4.00

5.00 0 154,100 0 0 0 5.00

6.00 0 208,000 0 0 0 6.00

7.00 0 208,000 0 0 0 7.00

8.00 0 208,000 0 0 0 8.00

9.00 0 225,300 0 0 0 9.00

10.00 0 177,200 0 0 0 10.00

11.00 0 208,000 0 0 0 11.00

12.00 0 208,000 0 0 0 12.00

200.00 0 0 0 0 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8-2

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost of

Memberships &

Continuing

Education

Provider

Component

Share of col.

12

Physician Cost

of Malpractice

Insurance

Provider

Component

Share of col.

14

Adjusted RCE

Limit

12.00 13.00 14.00 15.00 16.00

1.00 0 0 0 0 0 1.00

2.00 0 0 0 0 0 2.00

3.00 0 0 0 0 0 3.00

4.00 0 0 0 0 0 4.00

5.00 0 0 0 0 0 5.00

6.00 0 0 0 0 0 6.00

7.00 0 0 0 0 0 7.00

8.00 0 0 0 0 0 8.00

9.00 0 0 0 0 0 9.00

10.00 0 0 0 0 0 10.00

11.00 0 0 0 0 0 11.00

12.00 0 0 0 0 0 12.00

200.00 0 0 0 0 0 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet A-8-2

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


RCE

Disallowance

Adjustment

17.00 18.00

1.00 0 1,940,805 1.00

2.00 0 1,637,218 2.00

3.00 0 324,553 3.00

4.00 0 225,660 4.00

5.00 0 173,268 5.00

6.00 0 396,800 6.00

7.00 0 1,058,385 7.00

8.00 0 1,000 8.00

9.00 0 150,000 9.00

10.00 0 152,000 10.00

11.00 0 22,675 11.00

12.00 0 13,385 12.00

200.00 0 6,095,749 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208COST ALLOCATION - GENERAL SERVICE COSTS

CAPITAL RELATED COSTS

Cost Center Description Net Expenses

for Cost

Allocation

(from Wkst A

col. 7)

NEW BLDG &

FIXT

NEW MVBLE

EQUIP

EMPLOYEE

BENEFITS

NONPATIENT

TELEPHONES

0 1.00 2.00 4.00 5.01


1.00 NEW CAP REL COSTS-BLDG & FIXT 15,119,836 15,119,836 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 14,166,381 14,166,381 2.00

4.00 EMPLOYEE BENEFITS 73,076,796 13,708 1,562 73,092,066 4.00

5.01 NONPATIENT TELEPHONES 2,088,532 12,301 38,975 134,413 2,274,221 5.01

5.02 DATA PROCESSING 11,676,046 175,652 3,264 408 24,744 5.02

5.03 PURCHASING RECEIVING AND STORES 3,885,535 36,282 330,385 359,888 24,744 5.03

5.04 ADMITTING 1,645,927 11,349 16,566 318,723 19,121 5.04

5.05 ADMINISTRATIVE & GENERAL 14,380,509 15,841 116,625 1,386,457 125,971 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 62,251,615 2,869,052 567,625 4,808,092 202,453 5.06

6.00 MAINTENANCE & REPAIRS 21,386,073 4,537,346 345,790 776,025 114,723 6.00


8.00 LAUNDRY & LINEN SERVICE 3,468,692 3,099 0 0 0 8.00

9.00 HOUSEKEEPING 9,729,713 2,474 24,936 1,535,830 14,622 9.00

10.00 DIETARY 7,007,726 9,518 50,202 1,169,975 49,488 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 2,952,433 58,297 112,483 554,187 30,368 13.00

15.00 PHARMACY 8,736,308 37,868 200,724 2,099,105 37,116 15.00

16.00 MEDICAL RECORDS & LIBRARY 6,301,603 39,448 18,165 763,746 58,486 16.00

17.00 SOCIAL SERVICE 2,041,119 0 0 406,820 20,245 17.00


21.00 I&R SERVICES-SALARY & FRINGES APPRVD 12,557,885 0 0 3,431,376 0 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 12,808,623 713 2,248 0 64,110 22.00

23.00 PARAMEDIC 526,178 22,754 71,799 122,418 13,497 23.00

23.01 PASTORAL CARE 275,921 1,797 238 65,882 5,624 23.01

23.02 PHARMACY RESIDENCY 184,583 161 865 40,741 0 23.02


30.00 ADULTS & PEDIATRICS 94,418,874 1,179,981 887,538 19,852,091 389,160 30.00

31.00 INTENSIVE CARE UNIT 31,832,574 139,479 701,651 6,328,891 42,740 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 8,112,725 380,669 381,968 1,746,914 40,491 31.01




40.00 SUBPROVIDER - IPF 4,447,143 41,742 7,650 998,634 83,231 40.00

41.00 SUBPROVIDER - IRF 6,060,695 64,185 11,299 1,289,003 25,869 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 3,978,918 214,484 168,168 850,207 37,116 43.00


50.00 OPERATING ROOM 34,283,249 1,683,679 4,257,369 5,681,834 150,715 50.00

51.00 RECOVERY ROOM 4,047,784 0 1,321 868,111 8,998 51.00

52.00 DELIVERY ROOM & LABOR ROOM 7,918,479 121,698 323,725 1,588,328 28,118 52.00

53.00 ANESTHESIOLOGY 1,431,016 0 216,327 182,556 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 28,241,200 1,857,896 3,044,613 4,632,921 176,584 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 23,543,874 443,493 9,639 40,208 102,351 60.00

60.01 BLOOD LABORATORY 3,689,058 1,430 0 0 8,998 60.01


65.00 RESPIRATORY THERAPY 13,159,029 4,954 412,582 2,773,923 29,243 65.00

66.00 PHYSICAL THERAPY 3,925,663 56,635 44,198 1,118,034 23,620 66.00

67.00 OCCUPATIONAL THERAPY 4,871,606 414 11,566 1,037,357 53,987 67.00


69.00 ELECTROCARDIOLOGY 3,820,145 85 637,566 765,003 41,615 69.00

70.00 ELECTROENCEPHALOGRAPHY 403,393 53,459 59,294 85,680 5,624 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 69,783,213 0 0 0 0 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 45,240,421 0 0 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 33,684,485 0 0 0 0 73.00

74.00 RENAL DIALYSIS 1,604,745 347,111 91,299 329,175 0 74.00

76.00 DEV EVALUATION 1,152,744 1,293 9,778 246,223 26,994 76.00

76.97 CARDIAC REHABILITATION 833,606 0 5,842 182,716 0 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 1,885,382 1,834 7,445 353,500 55,112 90.03


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Cost Center Description Net Expenses

for Cost

Allocation

(from Wkst A

col. 7)

NEW BLDG &

FIXT

NEW MVBLE

EQUIP

EMPLOYEE

BENEFITS

NONPATIENT

TELEPHONES

0 1.00 2.00 4.00 5.01

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 20,444,871 675,987 602,746 3,634,279 112,474 91.00



99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 739,082,926 15,118,168 13,796,036 72,559,674 2,248,352 118.00



190.01 OTHER NONREIMB 4,497,285 1,668 370,345 532,392 25,869 190.01

190.02 OTHER 0 0 0 0 0 190.02

200.00 Cross Foot Adjustments 200.00

201.00 Negative Cost Centers 0 0 0 0 201.00

202.00 TOTAL (sum lines 118-201) 743,580,772 15,119,836 14,166,381 73,092,066 2,274,221 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES

ADMITTING ADMINISTRATIVE

& GENERAL

Subtotal

5.02 5.03 5.04 5.05 5A.05


1.00 NEW CAP REL COSTS-BLDG & FIXT 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 2.00

4.00 EMPLOYEE BENEFITS 4.00

5.01 NONPATIENT TELEPHONES 5.01

5.02 DATA PROCESSING 11,880,114 5.02

5.03 PURCHASING RECEIVING AND STORES 0 4,636,834 5.03

5.04 ADMITTING 0 1,921 2,013,607 5.04

5.05 ADMINISTRATIVE & GENERAL 0 12,084 0 16,037,487 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 0 41,781 0 0 70,740,618 5.06

6.00 MAINTENANCE & REPAIRS 0 37,573 0 0 27,197,530 6.00


8.00 LAUNDRY & LINEN SERVICE 0 119 0 0 3,471,910 8.00

9.00 HOUSEKEEPING 0 22,678 0 0 11,330,253 9.00

10.00 DIETARY 0 219,690 0 0 8,506,599 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 0 12,352 0 0 3,720,120 13.00

15.00 PHARMACY 0 9,314 0 0 11,120,435 15.00

16.00 MEDICAL RECORDS & LIBRARY 0 3,130 0 0 7,184,578 16.00

17.00 SOCIAL SERVICE 0 86 0 0 2,468,270 17.00


21.00 I&R SERVICES-SALARY & FRINGES APPRVD 0 0 0 0 15,989,261 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 10,865 0 0 12,886,559 22.00

23.00 PARAMEDIC 0 1,251 0 0 757,897 23.00

23.01 PASTORAL CARE 0 349 0 0 349,811 23.01

23.02 PHARMACY RESIDENCY 0 40 0 0 226,390 23.02


30.00 ADULTS & PEDIATRICS 1,334,705 282,608 298,695 1,801,865 120,445,517 30.00

31.00 INTENSIVE CARE UNIT 562,319 143,773 128,136 759,137 40,638,700 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 157,938 32,085 35,989 213,218 11,101,997 31.01




40.00 SUBPROVIDER - IPF 76,587 2,790 17,452 103,393 5,778,622 40.00

41.00 SUBPROVIDER - IRF 77,822 11,480 17,733 105,061 7,663,147 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 67,273 13,931 15,330 90,820 5,436,247 43.00


50.00 OPERATING ROOM 1,294,866 2,104,396 199,380 1,748,083 51,403,571 50.00

51.00 RECOVERY ROOM 206,281 2,437 24,010 278,482 5,437,424 51.00

52.00 DELIVERY ROOM & LABOR ROOM 180,515 47,615 30,649 243,697 10,482,824 52.00

53.00 ANESTHESIOLOGY 253,400 42,504 36,555 342,093 2,504,451 53.00

54.00 RADIOLOGY-DIAGNOSTIC 1,459,619 547,615 169,148 1,970,500 42,100,096 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 975,488 278,736 156,161 1,316,919 26,866,869 60.00

60.01 BLOOD LABORATORY 159,234 43,025 30,434 214,968 4,147,147 60.01


65.00 RESPIRATORY THERAPY 587,170 177,637 128,532 792,685 18,065,755 65.00

66.00 PHYSICAL THERAPY 227,045 381,405 33,035 306,513 6,116,148 66.00

67.00 OCCUPATIONAL THERAPY 96,431 11,200 13,863 130,182 6,226,606 67.00


69.00 ELECTROCARDIOLOGY 258,393 8,076 36,033 348,833 5,915,749 69.00

70.00 ELECTROENCEPHALOGRAPHY 15,364 476 1,992 20,742 646,024 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 565,285 0 107,071 763,140 71,218,709 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 811,688 0 151,307 1,095,787 47,299,203 72.00

73.00 DRUGS CHARGED TO PATIENTS 1,510,326 0 281,943 2,038,166 37,514,920 73.00

74.00 RENAL DIALYSIS 40,132 11,740 9,133 54,179 2,487,514 74.00

76.00 DEV EVALUATION 16,117 1,609 1,578 21,758 1,478,094 76.00

76.97 CARDIAC REHABILITATION 14,989 668 1,372 20,235 1,059,428 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 30,938 12,897 139 41,767 2,389,014 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 900,189 99,065 87,937 1,215,264 27,772,812 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0 92.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES


& GENERAL

Subtotal

5.02 5.03 5.04 5.05 5A.05


99.10 CORF 0 0 0 0 0 99.10








190.01 OTHER NONREIMB 0 5,833 0 0 5,433,392 190.01

190.02 OTHER 0 0 0 0 0 190.02

200.00 Cross Foot Adjustments 0 200.00

201.00 Negative Cost Centers 0 0 0 0 0 201.00

202.00 TOTAL (sum lines 118-201) 11,880,114 4,636,834 2,013,607 16,037,487 743,580,772 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description OTHER

ADMINISTRATIVE

AND GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

HOUSEKEEPING

5.06 6.00 7.00 8.00 9.00






5.02 DATA PROCESSING 5.02

5.03 PURCHASING RECEIVING AND STORES 5.03

5.04 ADMITTING 5.04

5.05 ADMINISTRATIVE & GENERAL 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 70,740,618 5.06

6.00 MAINTENANCE & REPAIRS 2,859,467 30,056,997 6.00

7.00 OPERATION OF PLANT 0 0 0 7.00

8.00 LAUNDRY & LINEN SERVICE 365,026 78,506 0 3,915,442 8.00

9.00 HOUSEKEEPING 1,191,229 334,658 0 0 12,856,140 9.00

10.00 DIETARY 894,358 1,090,618 0 0 601,467 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 391,122 236,640 0 0 144,288 13.00

15.00 PHARMACY 1,169,169 417,731 0 0 143,306 15.00

16.00 MEDICAL RECORDS & LIBRARY 755,365 237,221 0 0 104,256 16.00

17.00 SOCIAL SERVICE 259,507 48,864 0 0 18,420 17.00


21.00 I&R SERVICES-SALARY & FRINGES APPRVD 1,681,063 0 0 0 0 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 1,354,854 579,518 0 0 132,745 22.00

23.00 PARAMEDIC 79,683 54,718 0 11,022 95,169 23.00

23.01 PASTORAL CARE 36,778 29,808 0 0 10,069 23.01

23.02 PHARMACY RESIDENCY 23,802 1,785 0 0 368 23.02


30.00 ADULTS & PEDIATRICS 12,663,504 9,960,323 0 1,998,738 2,206,691 30.00

31.00 INTENSIVE CARE UNIT 4,272,631 2,330,609 0 449,815 901,341 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 1,167,231 143,603 0 46,989 30,822 31.01




40.00 SUBPROVIDER - IPF 607,547 646,233 0 57,477 173,514 40.00

41.00 SUBPROVIDER - IRF 805,680 633,198 0 77,008 136,920 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 571,551 200,894 0 30,134 98,976 43.00


50.00 OPERATING ROOM 5,404,417 3,930,001 0 112,890 487,264 50.00

51.00 RECOVERY ROOM 571,674 367,248 0 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 1,102,133 1,071,520 0 88,009 31,805 52.00

53.00 ANESTHESIOLOGY 263,310 48,532 0 0 6,386 53.00

54.00 RADIOLOGY-DIAGNOSTIC 4,426,278 2,916,063 0 513,622 1,831,662 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 2,824,702 871,747 0 27,313 448,951 60.00

60.01 BLOOD LABORATORY 436,019 91,708 0 0 27,138 60.01


65.00 RESPIRATORY THERAPY 1,899,379 143,893 0 0 145,148 65.00

66.00 PHYSICAL THERAPY 643,033 293,184 0 92,778 223,739 66.00

67.00 OCCUPATIONAL THERAPY 654,647 221,528 0 0 319,767 67.00


69.00 ELECTROCARDIOLOGY 621,964 274,875 0 38,005 135,201 69.00

70.00 ELECTROENCEPHALOGRAPHY 67,921 4,318 0 29,940 31,559 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 7,487,721 535,304 0 0 790,085 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 4,972,896 0 0 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 3,944,206 0 0 0 0 73.00

74.00 RENAL DIALYSIS 261,530 139,285 0 0 18,051 74.00

76.00 DEV EVALUATION 155,402 192,218 0 0 76,135 76.00

76.97 CARDIAC REHABILITATION 111,385 61,526 0 0 0 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 251,174 290,859 0 28,739 244,123 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 2,919,950 1,463,802 0 259,818 1,566,908 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ADMINISTRATIVE

AND GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

HOUSEKEEPING

5.06 6.00 7.00 8.00 9.00


99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 70,169,308 29,942,538 0 3,862,297 11,182,274 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 59 86,187 0 0 49,119 190.00

190.01 OTHER NONREIMB 571,251 28,272 0 53,145 1,624,747 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 TOTAL (sum lines 118-201) 70,740,618 30,056,997 0 3,915,442 12,856,140 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description DIETARY CAFETERIA NURSING

ADMINISTRATION

PHARMACY MEDICAL

RECORDS &

LIBRARY

10.00 11.00 13.00 15.00 16.00








5.04 ADMITTING 5.04


5.06 OTHER ADMINISTRATIVE AND GENERAL 5.06

6.00 MAINTENANCE & REPAIRS 6.00

7.00 OPERATION OF PLANT 7.00

8.00 LAUNDRY & LINEN SERVICE 8.00

9.00 HOUSEKEEPING 9.00

10.00 DIETARY 11,093,042 10.00

11.00 CAFETERIA 5,363,876 5,363,876 11.00

13.00 NURSING ADMINISTRATION 0 36,671 4,528,841 13.00

15.00 PHARMACY 0 139,633 0 12,990,274 15.00

16.00 MEDICAL RECORDS & LIBRARY 0 91,678 907 0 8,374,005 16.00

17.00 SOCIAL SERVICE 0 39,492 1,213 0 6,373 17.00


21.00 I&R SERVICES-SALARY & FRINGES APPRVD 0 0 0 0 0 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 208,744 4,084 0 0 22.00

23.00 PARAMEDIC 0 11,283 24 4,418 0 23.00

23.01 PASTORAL CARE 0 5,642 0 0 0 23.01

23.02 PHARMACY RESIDENCY 0 4,231 0 0 0 23.02


30.00 ADULTS & PEDIATRICS 4,227,135 1,819,460 2,094,318 3,263,214 2,893,937 30.00

31.00 INTENSIVE CARE UNIT 848,948 506,345 644,638 1,895,780 12,230 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 0 135,402 175,387 387,467 534,313 31.01




40.00 SUBPROVIDER - IPF 283,031 81,805 110,854 5,941 395,481 40.00

41.00 SUBPROVIDER - IRF 370,052 115,655 122,924 60,729 418,046 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 0 67,701 95,132 138,884 98,870 43.00


50.00 OPERATING ROOM 0 493,651 395,121 2,847,517 1,006,789 50.00

51.00 RECOVERY ROOM 0 66,290 50,459 9,566 42,028 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0 142,454 188,400 393,755 66,143 52.00

53.00 ANESTHESIOLOGY 0 19,746 18,717 536,081 27,732 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0 382,227 37,643 430,370 866,407 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 1,410 0 0 305,396 60.00

60.01 BLOOD LABORATORY 0 0 0 0 20,325 60.01


65.00 RESPIRATORY THERAPY 0 260,930 6,177 6,119 101,799 65.00

66.00 PHYSICAL THERAPY 0 91,678 4,071 72,224 73,378 66.00

67.00 OCCUPATIONAL THERAPY 0 93,089 4,304 7,052 46,851 67.00


69.00 ELECTROCARDIOLOGY 0 74,753 86,773 77,444 504,859 69.00

70.00 ELECTROENCEPHALOGRAPHY 0 8,463 7,286 0 4,995 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 0 0 0 0 71.00



73.00 DRUGS CHARGED TO PATIENTS 0 0 0 0 93,875 73.00

74.00 RENAL DIALYSIS 0 23,977 27,893 13,317 2,756 74.00

76.00 DEV EVALUATION 0 19,746 0 0 0 76.00

76.97 CARDIAC REHABILITATION 0 14,104 20,309 1,938 0 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 28,209 26,408 271,001 1,206 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 0 334,273 405,799 2,561,952 850,216 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ADMINISTRATION

PHARMACY MEDICAL

RECORDS &

LIBRARY

10.00 11.00 13.00 15.00 16.00


99.10 CORF 0 0 0 0 0 99.10








190.01 OTHER NONREIMB 0 45,134 0 5,505 0 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 TOTAL (sum lines 118-201) 11,093,042 5,363,876 4,528,841 12,990,274 8,374,005 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


INTERNS & RESIDENTS

Cost Center Description SOCIAL SERVICE Subtotal NONPHYSICIAN

ANESTHETISTS

SERVICES-SALAR

Y & FRINGES

SERVICES-OTHER

PRGM COSTS

17.00 17A 19.00 21.00 22.00








5.04 ADMITTING 5.04







10.00 DIETARY 10.00

11.00 CAFETERIA 11.00

13.00 NURSING ADMINISTRATION 13.00

15.00 PHARMACY 15.00

16.00 MEDICAL RECORDS & LIBRARY 16.00

17.00 SOCIAL SERVICE 2,842,139 17.00

19.00 NONPHYSICIAN ANESTHETISTS 0 0 0 19.00

21.00 I&R SERVICES-SALARY & FRINGES APPRVD 0 17,670,324 0 17,670,324 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 15,166,504 0 0 15,166,504 22.00

23.00 PARAMEDIC 0 1,014,214 0 0 0 23.00

23.01 PASTORAL CARE 0 432,108 0 0 0 23.01

23.02 PHARMACY RESIDENCY 0 256,576 0 0 0 23.02


30.00 ADULTS & PEDIATRICS 2,225,599 163,798,436 0 9,523,102 8,173,713 30.00

31.00 INTENSIVE CARE UNIT 446,964 52,948,001 0 1,911,219 1,640,407 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 169,576 13,892,787 0 725,884 623,029 31.01




40.00 SUBPROVIDER - IPF 0 8,140,505 0 0 0 40.00

41.00 SUBPROVIDER - IRF 0 10,403,359 0 0 0 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 0 6,738,389 0 0 0 43.00


50.00 OPERATING ROOM 0 66,081,221 0 1,951,638 1,675,098 50.00

51.00 RECOVERY ROOM 0 6,544,689 0 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0 13,567,043 0 0 0 52.00

53.00 ANESTHESIOLOGY 0 3,424,955 0 324,173 278,239 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0 53,504,368 0 0 0 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 31,346,388 0 0 0 60.00

60.01 BLOOD LABORATORY 0 4,722,337 0 0 0 60.01


65.00 RESPIRATORY THERAPY 0 20,629,200 0 0 0 65.00

66.00 PHYSICAL THERAPY 0 7,610,233 0 0 0 66.00

67.00 OCCUPATIONAL THERAPY 0 7,573,844 0 0 0 67.00


69.00 ELECTROCARDIOLOGY 0 7,729,623 0 301,077 258,415 69.00

70.00 ELECTROENCEPHALOGRAPHY 0 800,506 0 0 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 80,031,819 0 0 0 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 0 52,272,099 0 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 41,553,001 0 0 0 73.00

74.00 RENAL DIALYSIS 0 2,974,323 0 0 0 74.00

76.00 DEV EVALUATION 0 1,921,595 0 0 0 76.00

76.97 CARDIAC REHABILITATION 0 1,268,690 0 0 0 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 3,530,733 0 0 0 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 0 38,135,530 0 2,933,231 2,517,603 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


INTERNS & RESIDENTS

Cost Center Description SOCIAL SERVICE Subtotal NONPHYSICIAN

ANESTHETISTS

SERVICES-SALAR

Y & FRINGES

SERVICES-OTHER

PRGM COSTS

17.00 17A 19.00 21.00 22.00


99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 2,842,139 735,683,400 0 17,670,324 15,166,504 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 135,926 0 0 0 190.00

190.01 OTHER NONREIMB 0 7,761,446 0 0 0 190.01

190.02 OTHER 0 0 0 0 0 190.02

200.00 Cross Foot Adjustments 0 0 0 0 200.00


202.00 TOTAL (sum lines 118-201) 2,842,139 743,580,772 0 17,670,324 15,166,504 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Subtotal PARAMEDIC PASTORAL CARE Subtotal PHARMACY

RESIDENCY

22A 23.00 23.01 23A.01 23.02








5.04 ADMITTING 5.04







10.00 DIETARY 10.00





17.00 SOCIAL SERVICE 17.00

19.00 NONPHYSICIAN ANESTHETISTS 19.00

21.00 I&R SERVICES-SALARY & FRINGES APPRVD 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 22.00

23.00 PARAMEDIC 1,014,214 1,014,214 23.00

23.01 PASTORAL CARE 432,108 590 432,698 23.01

23.02 PHARMACY RESIDENCY 256,576 350 0 256,926 256,926 23.02


30.00 ADULTS & PEDIATRICS 181,495,251 247,792 285,568 182,028,611 62,718 30.00

31.00 INTENSIVE CARE UNIT 56,499,627 77,178 57,351 56,634,156 19,595 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 15,241,700 20,820 21,757 15,284,277 5,288 31.01




40.00 SUBPROVIDER - IPF 8,140,505 11,120 19,120 8,170,745 2,827 40.00

41.00 SUBPROVIDER - IRF 10,403,359 14,211 24,999 10,442,569 3,613 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 6,738,389 9,205 23,903 6,771,497 2,343 43.00


50.00 OPERATING ROOM 69,707,957 95,221 0 69,803,178 24,152 50.00

51.00 RECOVERY ROOM 6,544,689 8,940 0 6,553,629 2,268 51.00

52.00 DELIVERY ROOM & LABOR ROOM 13,567,043 18,533 0 13,585,576 4,701 52.00

53.00 ANESTHESIOLOGY 4,027,367 5,501 0 4,032,868 1,395 53.00

54.00 RADIOLOGY-DIAGNOSTIC 53,504,368 73,087 0 53,577,455 18,538 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 31,346,388 42,819 0 31,389,207 10,861 60.00

60.01 BLOOD LABORATORY 4,722,337 6,451 0 4,728,788 1,636 60.01


65.00 RESPIRATORY THERAPY 20,629,200 28,179 0 20,657,379 7,147 65.00

66.00 PHYSICAL THERAPY 7,610,233 10,396 0 7,620,629 2,637 66.00

67.00 OCCUPATIONAL THERAPY 7,573,844 10,346 0 7,584,190 2,624 67.00


69.00 ELECTROCARDIOLOGY 8,289,115 11,323 0 8,300,438 2,872 69.00

70.00 ELECTROENCEPHALOGRAPHY 800,506 1,093 0 801,599 277 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 80,031,819 109,323 0 80,141,142 27,729 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 52,272,099 71,404 0 52,343,503 18,111 72.00

73.00 DRUGS CHARGED TO PATIENTS 41,553,001 56,761 0 41,609,762 14,397 73.00

74.00 RENAL DIALYSIS 2,974,323 4,063 0 2,978,386 1,031 74.00

76.00 DEV EVALUATION 1,921,595 2,625 0 1,924,220 666 76.00

76.97 CARDIAC REHABILITATION 1,268,690 1,733 0 1,270,423 440 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 3,530,733 4,823 0 3,535,556 1,223 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 43,586,364 59,539 0 43,645,903 15,101 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0 0 92.00


99.10 CORF 0 0 0 0 0 99.10


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Subtotal PARAMEDIC PASTORAL CARE Subtotal PHARMACY

RESIDENCY

22A 23.00 23.01 23A.01 23.02





118.00 SUBTOTALS (SUM OF LINES 1-117) 735,683,400 1,003,426 432,698 735,672,612 254,190 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 135,926 186 0 136,112 47 190.00

190.01 OTHER NONREIMB 7,761,446 10,602 0 7,772,048 2,689 190.01

190.02 OTHER 0 0 0 0 0 190.02

200.00 Cross Foot Adjustments 0 0 0 0 0 200.00


202.00 TOTAL (sum lines 118-201) 743,580,772 1,014,214 432,698 743,580,772 256,926 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Subtotal Intern &

Residents Cost

& Post

Stepdown

Adjustments

Total

24.00 25.00 26.00








5.04 ADMITTING 5.04







10.00 DIETARY 10.00









23.00 PARAMEDIC 23.00

23.01 PASTORAL CARE 23.01

23.02 PHARMACY RESIDENCY 23.02


30.00 ADULTS & PEDIATRICS 182,091,329 -17,696,815 164,394,514 30.00

31.00 INTENSIVE CARE UNIT 56,653,751 -3,551,626 53,102,125 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 15,289,565 -1,348,913 13,940,652 31.01

32.00 CORONARY CARE UNIT 0 0 0 32.00

33.00 BURN INTENSIVE CARE UNIT 0 0 0 33.00

34.00 SURGICAL INTENSIVE CARE UNIT 0 0 0 34.00

40.00 SUBPROVIDER - IPF 8,173,572 0 8,173,572 40.00

41.00 SUBPROVIDER - IRF 10,446,182 0 10,446,182 41.00

42.00 SUBPROVIDER 0 0 0 42.00

43.00 NURSERY 6,773,840 0 6,773,840 43.00


50.00 OPERATING ROOM 69,827,330 -3,626,736 66,200,594 50.00

51.00 RECOVERY ROOM 6,555,897 0 6,555,897 51.00

52.00 DELIVERY ROOM & LABOR ROOM 13,590,277 0 13,590,277 52.00

53.00 ANESTHESIOLOGY 4,034,263 -602,412 3,431,851 53.00

54.00 RADIOLOGY-DIAGNOSTIC 53,595,993 0 53,595,993 54.00

57.00 CT SCAN 0 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0 0 0 59.00

60.00 LABORATORY 31,400,068 0 31,400,068 60.00

60.01 BLOOD LABORATORY 4,730,424 0 4,730,424 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 0 62.00

65.00 RESPIRATORY THERAPY 20,664,526 0 20,664,526 65.00

66.00 PHYSICAL THERAPY 7,623,266 0 7,623,266 66.00

67.00 OCCUPATIONAL THERAPY 7,586,814 0 7,586,814 67.00

68.00 SPEECH PATHOLOGY 0 0 0 68.00

69.00 ELECTROCARDIOLOGY 8,303,310 -559,492 7,743,818 69.00

70.00 ELECTROENCEPHALOGRAPHY 801,876 0 801,876 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 80,168,871 0 80,168,871 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 52,361,614 0 52,361,614 72.00

73.00 DRUGS CHARGED TO PATIENTS 41,624,159 0 41,624,159 73.00

74.00 RENAL DIALYSIS 2,979,417 0 2,979,417 74.00

76.00 DEV EVALUATION 1,924,886 0 1,924,886 76.00

76.97 CARDIAC REHABILITATION 1,270,863 0 1,270,863 76.97


88.00 RURAL HEALTH CLINIC 0 0 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0 0 0 89.00

90.00 CLINIC 0 0 0 90.00

90.01 FAMILY PRACTICES 0 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 0 90.02

90.03 AMBULATORY CARE 3,536,779 0 3,536,779 90.03

90.04 OTHER 0 0 0 90.04

91.00 EMERGENCY 43,661,004 -5,450,834 38,210,170 91.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description Subtotal Intern &

Residents Cost

& Post

Stepdown

Adjustments

Total

24.00 25.00 26.00



99.10 CORF 0 0 0 99.10


109.00 PANCREAS ACQUISITION 0 0 0 109.00

110.00 INTESTINAL ACQUISITION 0 0 0 110.00

111.00 ISLET ACQUISITION 0 0 0 111.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 735,669,876 -32,836,828 702,833,048 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 136,159 0 136,159 190.00

190.01 OTHER NONREIMB 7,774,737 0 7,774,737 190.01

190.02 OTHER 0 0 0 190.02

200.00 Cross Foot Adjustments 0 0 0 200.00

201.00 Negative Cost Centers 0 0 0 201.00

202.00 TOTAL (sum lines 118-201) 743,580,772 -32,836,828 710,743,944 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208ALLOCATION OF CAPITAL RELATED COSTS


Cost Center Description Directly

Assigned New

Capital

Related Costs

NEW BLDG &

FIXT

NEW MVBLE

EQUIP

Subtotal EMPLOYEE

BENEFITS

0 1.00 2.00 2A 4.00




4.00 EMPLOYEE BENEFITS 11 13,708 1,562 15,281 15,281 4.00

5.01 NONPATIENT TELEPHONES 0 12,301 38,975 51,276 28 5.01

5.02 DATA PROCESSING 0 175,652 3,264 178,916 0 5.02

5.03 PURCHASING RECEIVING AND STORES 1,155,183 36,282 330,385 1,521,850 75 5.03

5.04 ADMITTING 0 11,349 16,566 27,915 66 5.04

5.05 ADMINISTRATIVE & GENERAL 0 15,841 116,625 132,466 287 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 142,771 2,869,052 567,625 3,579,448 995 5.06

6.00 MAINTENANCE & REPAIRS 9,893 4,537,346 345,790 4,893,029 161 6.00


8.00 LAUNDRY & LINEN SERVICE 0 3,099 0 3,099 0 8.00

9.00 HOUSEKEEPING 0 2,474 24,936 27,410 318 9.00

10.00 DIETARY 6,071 9,518 50,202 65,791 242 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 0 58,297 112,483 170,780 115 13.00

15.00 PHARMACY 21,699 37,868 200,724 260,291 435 15.00

16.00 MEDICAL RECORDS & LIBRARY 0 39,448 18,165 57,613 158 16.00

17.00 SOCIAL SERVICE 0 0 0 0 84 17.00



22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 713 2,248 2,961 0 22.00

23.00 PARAMEDIC 0 22,754 71,799 94,553 25 23.00

23.01 PASTORAL CARE 0 1,797 238 2,035 14 23.01

23.02 PHARMACY RESIDENCY 0 161 865 1,026 8 23.02


30.00 ADULTS & PEDIATRICS 1,414,029 1,179,981 887,538 3,481,548 4,260 30.00

31.00 INTENSIVE CARE UNIT 16,405 139,479 701,651 857,535 1,310 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 30,563 380,669 381,968 793,200 362 31.01




40.00 SUBPROVIDER - IPF 0 41,742 7,650 49,392 207 40.00

41.00 SUBPROVIDER - IRF 522 64,185 11,299 76,006 267 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 0 214,484 168,168 382,652 176 43.00


50.00 OPERATING ROOM 342,530 1,683,679 4,257,369 6,283,578 1,176 50.00

51.00 RECOVERY ROOM 0 0 1,321 1,321 180 51.00

52.00 DELIVERY ROOM & LABOR ROOM 80,162 121,698 323,725 525,585 329 52.00

53.00 ANESTHESIOLOGY 16,664 0 216,327 232,991 38 53.00

54.00 RADIOLOGY-DIAGNOSTIC 3,915,130 1,857,896 3,044,613 8,817,639 959 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 443,493 9,639 453,132 8 60.00

60.01 BLOOD LABORATORY 0 1,430 0 1,430 0 60.01


65.00 RESPIRATORY THERAPY 178,031 4,954 412,582 595,567 574 65.00

66.00 PHYSICAL THERAPY 5,775 56,635 44,198 106,608 231 66.00

67.00 OCCUPATIONAL THERAPY 5,775 414 11,566 17,755 215 67.00


69.00 ELECTROCARDIOLOGY 56 85 637,566 637,707 158 69.00

70.00 ELECTROENCEPHALOGRAPHY 0 53,459 59,294 112,753 18 70.00




73.00 DRUGS CHARGED TO PATIENTS 0 0 0 0 0 73.00

74.00 RENAL DIALYSIS 5,030 347,111 91,299 443,440 68 74.00

76.00 DEV EVALUATION 183 1,293 9,778 11,254 51 76.00

76.97 CARDIAC REHABILITATION 0 0 5,842 5,842 38 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 1,834 7,445 9,279 73 90.03

90.04 OTHER 0 0 0 0 0 90.04


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Cost Center Description Directly

Assigned New

Capital

Related Costs

NEW BLDG &

FIXT

NEW MVBLE

EQUIP

Subtotal EMPLOYEE

BENEFITS

0 1.00 2.00 2A 4.00

91.00 EMERGENCY 47,354 675,987 602,746 1,326,087 752 91.00



99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 7,393,837 15,118,168 13,796,036 36,308,041 15,171 118.00



190.01 OTHER NONREIMB 6,919 1,668 370,345 378,932 110 190.01

190.02 OTHER 0 0 0 0 0 190.02

200.00 Cross Foot Adjustments 0 200.00

201.00 Negative Cost Centers 0 0 0 0 201.00

202.00 TOTAL (sum lines 118-201) 7,400,756 15,119,836 14,166,381 36,686,973 15,281 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description NONPATIENT

TELEPHONES

DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES


& GENERAL

5.01 5.02 5.03 5.04 5.05





5.01 NONPATIENT TELEPHONES 51,304 5.01

5.02 DATA PROCESSING 558 179,474 5.02

5.03 PURCHASING RECEIVING AND STORES 558 0 1,522,483 5.03

5.04 ADMITTING 431 0 631 29,043 5.04

5.05 ADMINISTRATIVE & GENERAL 2,842 0 3,968 0 139,563 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 4,567 0 13,719 0 0 5.06

6.00 MAINTENANCE & REPAIRS 2,588 0 12,337 0 0 6.00


8.00 LAUNDRY & LINEN SERVICE 0 0 39 0 0 8.00

9.00 HOUSEKEEPING 330 0 7,446 0 0 9.00

10.00 DIETARY 1,116 0 72,135 0 0 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 685 0 4,056 0 0 13.00

15.00 PHARMACY 837 0 3,058 0 0 15.00

16.00 MEDICAL RECORDS & LIBRARY 1,319 0 1,028 0 0 16.00

17.00 SOCIAL SERVICE 457 0 28 0 0 17.00



22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 1,446 0 3,567 0 0 22.00

23.00 PARAMEDIC 304 0 411 0 0 23.00

23.01 PASTORAL CARE 127 0 115 0 0 23.01

23.02 PHARMACY RESIDENCY 0 0 13 0 0 23.02


30.00 ADULTS & PEDIATRICS 8,780 20,276 92,795 4,653 15,680 30.00

31.00 INTENSIVE CARE UNIT 964 8,542 47,208 1,822 6,606 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 913 2,399 10,535 512 1,855 31.01




40.00 SUBPROVIDER - IPF 1,878 1,163 916 248 900 40.00

41.00 SUBPROVIDER - IRF 584 1,182 3,769 252 914 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 837 1,022 4,574 218 790 43.00


50.00 OPERATING ROOM 3,400 19,671 690,958 2,836 15,212 50.00

51.00 RECOVERY ROOM 203 3,134 800 341 2,423 51.00

52.00 DELIVERY ROOM & LABOR ROOM 634 2,742 15,634 436 2,121 52.00

53.00 ANESTHESIOLOGY 0 3,850 13,956 520 2,977 53.00

54.00 RADIOLOGY-DIAGNOSTIC 3,984 22,174 179,810 2,406 17,148 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 2,309 14,819 91,523 2,221 11,460 60.00

60.01 BLOOD LABORATORY 203 2,419 14,127 433 1,871 60.01


65.00 RESPIRATORY THERAPY 660 8,920 58,327 1,828 6,898 65.00

66.00 PHYSICAL THERAPY 533 3,449 125,235 470 2,667 66.00

67.00 OCCUPATIONAL THERAPY 1,218 1,465 3,677 197 1,133 67.00


69.00 ELECTROCARDIOLOGY 939 3,925 2,652 512 3,036 69.00

70.00 ELECTROENCEPHALOGRAPHY 127 233 156 28 180 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 8,587 0 1,523 6,641 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 0 12,331 0 2,152 9,536 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 21,943 0 4,010 17,741 73.00

74.00 RENAL DIALYSIS 0 610 3,855 130 471 74.00

76.00 DEV EVALUATION 609 245 528 22 189 76.00

76.97 CARDIAC REHABILITATION 0 228 219 20 176 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 1,243 470 4,235 2 363 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 2,537 13,675 32,528 1,251 10,575 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description NONPATIENT

TELEPHONES

DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES


& GENERAL

5.01 5.02 5.03 5.04 5.05


99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 50,720 179,474 1,520,568 29,043 139,563 118.00



190.01 OTHER NONREIMB 584 0 1,915 0 0 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 TOTAL (sum lines 118-201) 51,304 179,474 1,522,483 29,043 139,563 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ADMINISTRATIVE

AND GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

HOUSEKEEPING

5.06 6.00 7.00 8.00 9.00








5.04 ADMITTING 5.04


5.06 OTHER ADMINISTRATIVE AND GENERAL 3,598,729 5.06

6.00 MAINTENANCE & REPAIRS 145,480 5,053,595 6.00

7.00 OPERATION OF PLANT 0 0 0 7.00

8.00 LAUNDRY & LINEN SERVICE 18,571 13,200 0 34,909 8.00

9.00 HOUSEKEEPING 60,606 56,267 0 0 152,377 9.00

10.00 DIETARY 45,502 183,370 0 0 7,129 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 19,899 39,787 0 0 1,710 13.00

15.00 PHARMACY 59,483 70,235 0 0 1,699 15.00

16.00 MEDICAL RECORDS & LIBRARY 38,430 39,885 0 0 1,236 16.00

17.00 SOCIAL SERVICE 13,203 8,216 0 0 218 17.00


21.00 I&R SERVICES-SALARY & FRINGES APPRVD 85,527 0 0 0 0 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 68,930 97,436 0 0 1,573 22.00

23.00 PARAMEDIC 4,054 9,200 0 98 1,128 23.00

23.01 PASTORAL CARE 1,871 5,012 0 0 119 23.01

23.02 PHARMACY RESIDENCY 1,211 300 0 0 4 23.02


30.00 ADULTS & PEDIATRICS 643,970 1,674,663 0 17,818 26,157 30.00

31.00 INTENSIVE CARE UNIT 217,376 391,854 0 4,011 10,683 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 59,385 24,144 0 419 365 31.01




40.00 SUBPROVIDER - IPF 30,910 108,654 0 512 2,057 40.00

41.00 SUBPROVIDER - IRF 40,990 106,462 0 687 1,623 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 29,078 33,777 0 269 1,173 43.00


50.00 OPERATING ROOM 274,958 660,766 0 1,007 5,775 50.00

51.00 RECOVERY ROOM 29,085 61,747 0 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 56,073 180,159 0 785 377 52.00

53.00 ANESTHESIOLOGY 13,396 8,160 0 0 76 53.00

54.00 RADIOLOGY-DIAGNOSTIC 225,193 490,289 0 4,579 21,710 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 143,711 146,570 0 244 5,321 60.00

60.01 BLOOD LABORATORY 22,183 15,419 0 0 322 60.01


65.00 RESPIRATORY THERAPY 96,634 24,193 0 0 1,720 65.00

66.00 PHYSICAL THERAPY 32,715 49,294 0 827 2,652 66.00

67.00 OCCUPATIONAL THERAPY 33,306 37,246 0 0 3,790 67.00


69.00 ELECTROCARDIOLOGY 31,643 46,216 0 339 1,602 69.00

70.00 ELECTROENCEPHALOGRAPHY 3,456 726 0 267 374 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 380,949 90,003 0 0 9,364 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 253,003 0 0 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 200,667 0 0 0 0 73.00

74.00 RENAL DIALYSIS 13,306 23,419 0 0 214 74.00

76.00 DEV EVALUATION 7,906 32,318 0 0 902 76.00





90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 12,779 48,903 0 256 2,893 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 148,557 246,115 0 2,317 18,572 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ADMINISTRATIVE

AND GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

HOUSEKEEPING

5.06 6.00 7.00 8.00 9.00


99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 3,569,663 5,034,350 0 34,435 132,538 118.00



190.01 OTHER NONREIMB 29,063 4,754 0 474 19,257 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 TOTAL (sum lines 118-201) 3,598,729 5,053,595 0 34,909 152,377 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ADMINISTRATION

PHARMACY MEDICAL

RECORDS &

LIBRARY

10.00 11.00 13.00 15.00 16.00








5.04 ADMITTING 5.04







10.00 DIETARY 375,285 10.00

11.00 CAFETERIA 181,464 181,464 11.00

13.00 NURSING ADMINISTRATION 0 1,241 238,273 13.00

15.00 PHARMACY 0 4,724 0 400,762 15.00

16.00 MEDICAL RECORDS & LIBRARY 0 3,102 48 0 142,819 16.00

17.00 SOCIAL SERVICE 0 1,336 64 0 109 17.00



22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 7,062 215 0 0 22.00

23.00 PARAMEDIC 0 382 1 136 0 23.00

23.01 PASTORAL CARE 0 191 0 0 0 23.01



30.00 ADULTS & PEDIATRICS 143,007 61,552 110,190 100,673 49,355 30.00

31.00 INTENSIVE CARE UNIT 28,720 17,130 33,916 58,486 209 31.00





40.00 SUBPROVIDER - IPF 9,575 2,768 5,832 183 6,745 40.00

41.00 SUBPROVIDER - IRF 12,519 3,913 6,467 1,874 7,130 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 0 2,290 5,005 4,285 1,686 43.00


50.00 OPERATING ROOM 0 16,701 20,788 87,848 17,171 50.00

51.00 RECOVERY ROOM 0 2,243 2,655 295 717 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0 4,819 9,912 12,148 1,128 52.00

53.00 ANESTHESIOLOGY 0 668 985 16,539 473 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0 12,931 1,980 13,277 14,777 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 48 0 0 5,209 60.00

60.01 BLOOD LABORATORY 0 0 0 0 347 60.01


65.00 RESPIRATORY THERAPY 0 8,827 325 189 1,736 65.00

66.00 PHYSICAL THERAPY 0 3,102 214 2,228 1,251 66.00

67.00 OCCUPATIONAL THERAPY 0 3,149 226 218 799 67.00


69.00 ELECTROCARDIOLOGY 0 2,529 4,565 2,389 8,610 69.00

70.00 ELECTROENCEPHALOGRAPHY 0 286 383 0 85 70.00




73.00 DRUGS CHARGED TO PATIENTS 0 0 0 0 1,601 73.00

74.00 RENAL DIALYSIS 0 811 1,468 411 47 74.00

76.00 DEV EVALUATION 0 668 0 0 0 76.00

76.97 CARDIAC REHABILITATION 0 477 1,068 60 0 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 954 1,389 8,361 21 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 0 11,309 21,350 79,038 14,500 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ADMINISTRATION

PHARMACY MEDICAL

RECORDS &

LIBRARY

10.00 11.00 13.00 15.00 16.00


99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 375,285 179,937 238,273 400,592 142,819 118.00



190.01 OTHER NONREIMB 0 1,527 0 170 0 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 TOTAL (sum lines 118-201) 375,285 181,464 238,273 400,762 142,819 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


INTERNS & RESIDENTS

Cost Center Description SOCIAL SERVICE NONPHYSICIAN

ANESTHETISTS

SERVICES-SALAR

Y & FRINGES

SERVICES-OTHER

PRGM COSTS

PARAMEDIC

17.00 19.00 21.00 22.00 23.00








5.04 ADMITTING 5.04







10.00 DIETARY 10.00





17.00 SOCIAL SERVICE 23,715 17.00

19.00 NONPHYSICIAN ANESTHETISTS 0 0 19.00

21.00 I&R SERVICES-SALARY & FRINGES APPRVD 0 86,237 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 183,190 22.00

23.00 PARAMEDIC 0 110,292 23.00

23.01 PASTORAL CARE 0 23.01

23.02 PHARMACY RESIDENCY 0 23.02


30.00 ADULTS & PEDIATRICS 18,570 30.00

31.00 INTENSIVE CARE UNIT 3,730 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 1,415 31.01

32.00 CORONARY CARE UNIT 0 32.00

33.00 BURN INTENSIVE CARE UNIT 0 33.00

34.00 SURGICAL INTENSIVE CARE UNIT 0 34.00




43.00 NURSERY 0 43.00


50.00 OPERATING ROOM 0 50.00

51.00 RECOVERY ROOM 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0 52.00

53.00 ANESTHESIOLOGY 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0 54.00

57.00 CT SCAN 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 58.00

59.00 CARDIAC CATHETERIZATION 0 59.00

60.00 LABORATORY 0 60.00

60.01 BLOOD LABORATORY 0 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 62.00

65.00 RESPIRATORY THERAPY 0 65.00

66.00 PHYSICAL THERAPY 0 66.00

67.00 OCCUPATIONAL THERAPY 0 67.00

68.00 SPEECH PATHOLOGY 0 68.00

69.00 ELECTROCARDIOLOGY 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 73.00

74.00 RENAL DIALYSIS 0 74.00

76.00 DEV EVALUATION 0 76.00

76.97 CARDIAC REHABILITATION 0 76.97


88.00 RURAL HEALTH CLINIC 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0 89.00

90.00 CLINIC 0 90.00

90.01 FAMILY PRACTICES 0 90.01

90.02 WOMEN'S HEALTH CENTER 0 90.02

90.03 AMBULATORY CARE 0 90.03

90.04 OTHER 0 90.04

91.00 EMERGENCY 0 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


INTERNS & RESIDENTS

Cost Center Description SOCIAL SERVICE NONPHYSICIAN

ANESTHETISTS

SERVICES-SALAR

Y & FRINGES

SERVICES-OTHER

PRGM COSTS

PARAMEDIC

17.00 19.00 21.00 22.00 23.00


99.10 CORF 0 99.10


109.00 PANCREAS ACQUISITION 0 109.00

110.00 INTESTINAL ACQUISITION 0 110.00

111.00 ISLET ACQUISITION 0 111.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 23,715 0 0 0 0 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 190.00

190.01 OTHER NONREIMB 0 190.01

190.02 OTHER 0 190.02

200.00 Cross Foot Adjustments 0 86,237 183,190 110,292 200.00


202.00 TOTAL (sum lines 118-201) 23,715 0 86,237 183,190 110,292 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description PASTORAL CARE PHARMACY

RESIDENCY

Subtotal Intern &

Residents Cost

& Post

Stepdown

Adjustments

Total

23.01 23.02 24.00 25.00 26.00








5.04 ADMITTING 5.04







10.00 DIETARY 10.00









23.00 PARAMEDIC 23.00

23.01 PASTORAL CARE 9,484 23.01

23.02 PHARMACY RESIDENCY 2,705 23.02


30.00 ADULTS & PEDIATRICS 6,473,947 0 6,473,947 30.00

31.00 INTENSIVE CARE UNIT 1,690,102 0 1,690,102 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 930,379 0 930,379 31.01

32.00 CORONARY CARE UNIT 0 0 0 32.00

33.00 BURN INTENSIVE CARE UNIT 0 0 0 33.00

34.00 SURGICAL INTENSIVE CARE UNIT 0 0 0 34.00

40.00 SUBPROVIDER - IPF 221,940 0 221,940 40.00

41.00 SUBPROVIDER - IRF 264,639 0 264,639 41.00

42.00 SUBPROVIDER 0 0 0 42.00

43.00 NURSERY 467,832 0 467,832 43.00


50.00 OPERATING ROOM 8,101,845 0 8,101,845 50.00

51.00 RECOVERY ROOM 105,144 0 105,144 51.00

52.00 DELIVERY ROOM & LABOR ROOM 812,882 0 812,882 52.00

53.00 ANESTHESIOLOGY 294,629 0 294,629 53.00

54.00 RADIOLOGY-DIAGNOSTIC 9,828,856 0 9,828,856 54.00

57.00 CT SCAN 0 0 0 57.00



60.00 LABORATORY 876,575 0 876,575 60.00

60.01 BLOOD LABORATORY 58,754 0 58,754 60.01


65.00 RESPIRATORY THERAPY 806,398 0 806,398 65.00

66.00 PHYSICAL THERAPY 331,476 0 331,476 66.00

67.00 OCCUPATIONAL THERAPY 104,394 0 104,394 67.00


69.00 ELECTROCARDIOLOGY 746,822 0 746,822 69.00

70.00 ELECTROENCEPHALOGRAPHY 119,072 0 119,072 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 497,067 0 497,067 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 277,022 0 277,022 72.00

73.00 DRUGS CHARGED TO PATIENTS 245,962 0 245,962 73.00

74.00 RENAL DIALYSIS 488,250 0 488,250 74.00

76.00 DEV EVALUATION 54,692 0 54,692 76.00

76.97 CARDIAC REHABILITATION 24,140 0 24,140 76.97




90.00 CLINIC 0 0 0 90.00



90.03 AMBULATORY CARE 91,221 0 91,221 90.03

90.04 OTHER 0 0 0 90.04

91.00 EMERGENCY 1,929,163 0 1,929,163 91.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description PASTORAL CARE PHARMACY

RESIDENCY

Subtotal Intern &

Residents Cost

& Post

Stepdown

Adjustments

Total

23.01 23.02 24.00 25.00 26.00



99.10 CORF 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 0 0 35,843,203 0 35,843,203 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 15,076 0 15,076 190.00

190.01 OTHER NONREIMB 436,786 0 436,786 190.01

190.02 OTHER 0 0 0 190.02

200.00 Cross Foot Adjustments 9,484 2,705 391,908 0 391,908 200.00


202.00 TOTAL (sum lines 118-201) 9,484 2,705 36,686,973 0 36,686,973 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208COST ALLOCATION - STATISTICAL BASIS


Cost Center Description NEW BLDG &

FIXT

(ACTUAL

DEPR)

NEW MVBLE

EQUIP

(EQUIP

DEPR NEW)

EMPLOYEE

BENEFITS

(GROSS

SALARIES)

NONPATIENT

TELEPHONES

(PHONES)

DATA

PROCESSING

(GROSS

CHARGES)

1.00 2.00 4.00 5.01 5.02


1.00 NEW CAP REL COSTS-BLDG & FIXT 11,146,998 1.00

2.00 NEW CAP REL COSTS-MVBLE EQUIP 9,873,727 2.00

4.00 EMPLOYEE BENEFITS 10,106 1,089 308,838,334 4.00

5.01 NONPATIENT TELEPHONES 9,069 27,165 567,937 2,022 5.01

5.02 DATA PROCESSING 129,498 2,275 1,722 22 2,406,381,258 5.02

5.03 PURCHASING RECEIVING AND STORES 26,749 230,273 1,520,645 22 0 5.03

5.04 ADMITTING 8,367 11,546 1,346,711 17 0 5.04

5.05 ADMINISTRATIVE & GENERAL 11,679 81,286 5,858,235 112 0 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 2,115,190 395,625 20,315,767 180 0 5.06

6.00 MAINTENANCE & REPAIRS 3,345,126 241,010 3,278,960 102 0 6.00


8.00 LAUNDRY & LINEN SERVICE 2,285 0 0 0 0 8.00

9.00 HOUSEKEEPING 1,824 17,380 6,489,386 13 0 9.00

10.00 DIETARY 7,017 34,990 4,943,528 44 0 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 42,979 78,399 2,341,622 27 0 13.00

15.00 PHARMACY 27,918 139,901 8,869,409 33 0 15.00

16.00 MEDICAL RECORDS & LIBRARY 29,083 12,661 3,227,076 52 0 16.00

17.00 SOCIAL SERVICE 0 0 1,718,950 18 0 17.00


21.00 I&R SERVICES-SALARY & FRINGES APPRVD 0 0 14,498,690 0 0 21.00


23.00 PARAMEDIC 16,775 50,043 517,255 12 0 23.00

23.01 PASTORAL CARE 1,325 166 278,375 5 0 23.01

23.02 PHARMACY RESIDENCY 119 603 172,142 0 0 23.02


30.00 ADULTS & PEDIATRICS 869,933 618,599 83,881,971 346 270,347,342 30.00

31.00 INTENSIVE CARE UNIT 102,830 489,039 26,741,641 38 113,899,016 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 280,646 266,225 7,381,285 36 31,990,650 31.01




40.00 SUBPROVIDER - IPF 30,774 5,332 4,219,557 74 15,512,871 40.00

41.00 SUBPROVIDER - IRF 47,320 7,875 5,446,459 23 15,763,100 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 158,127 117,210 3,592,402 33 13,626,360 43.00


50.00 OPERATING ROOM 1,241,281 2,967,311 24,007,615 134 262,277,988 50.00

51.00 RECOVERY ROOM 0 921 3,668,054 8 41,782,683 51.00

52.00 DELIVERY ROOM & LABOR ROOM 89,721 225,631 6,711,206 25 36,563,633 52.00

53.00 ANESTHESIOLOGY 0 150,776 771,361 0 51,326,787 53.00

54.00 RADIOLOGY-DIAGNOSTIC 1,369,722 2,122,044 19,575,611 157 295,648,937 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 326,962 6,718 169,890 91 197,587,190 60.00

60.01 BLOOD LABORATORY 1,054 0 0 8 32,253,237 60.01


65.00 RESPIRATORY THERAPY 3,652 287,563 11,720,735 26 118,932,516 65.00

66.00 PHYSICAL THERAPY 41,754 30,805 4,724,061 21 45,988,420 66.00

67.00 OCCUPATIONAL THERAPY 305 8,061 4,383,174 48 19,532,239 67.00


69.00 ELECTROCARDIOLOGY 63 444,373 3,232,390 37 52,338,067 69.00

70.00 ELECTROENCEPHALOGRAPHY 39,412 41,327 362,026 5 3,112,038 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 0 0 0 114,499,615 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 0 0 0 0 164,409,196 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 0 0 0 305,958,243 73.00

74.00 RENAL DIALYSIS 255,905 63,634 1,390,871 0 8,128,811 74.00

76.00 DEV EVALUATION 953 6,815 1,040,372 24 3,264,573 76.00

76.97 CARDIAC REHABILITATION 0 4,072 772,034 0 3,035,990 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 1,352 5,189 1,493,655 49 6,266,578 90.03

90.04 OTHER 0 0 0 0 0 90.04


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Cost Center Description NEW BLDG &

FIXT

(ACTUAL

DEPR)

NEW MVBLE

EQUIP

(EQUIP

DEPR NEW)

EMPLOYEE

BENEFITS

(GROSS

SALARIES)

NONPATIENT

TELEPHONES

(PHONES)

DATA

PROCESSING

(GROSS

CHARGES)

1.00 2.00 4.00 5.01 5.02

91.00 EMERGENCY 498,367 420,104 15,356,022 100 182,335,178 91.00



99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 11,145,768 9,615,603 306,588,802 1,999 2,406,381,258 118.00



190.01 OTHER NONREIMB 1,230 258,124 2,249,532 23 0 190.01

190.02 OTHER 0 0 0 0 0 190.02


201.00 Negative Cost Centers 201.00

202.00 Cost to be allocated (per Wkst. B, Part I) 15,119,836 14,166,381 73,092,066 2,274,221 11,880,114 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 1.356404 1.434755 0.236668 1,124.738378 0.004937 203.00

204.00 Cost to be allocated (per Wkst. B, Part II) 15,281 51,304 179,474 204.00

205.00 Unit cost multiplier (Wkst. B, Part II) 0.000049 25.372898 0.000075 205.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description PURCHASING

RECEIVING AND

STORES

(SUPPLIES

EXPENSE)

ADMITTING

(INPATIENT

CHARGES)

ADMINISTRATIVE

& GENERAL

(GROSS

CHARGES)

Reconciliation OTHER

ADMINISTRATIVE

AND GENERAL

(ACCUM.

COST)

5.03 5.04 5.05 5A.06 5.06







5.03 PURCHASING RECEIVING AND STORES 132,267,151 5.03

5.04 ADMITTING 54,789 1,790,621,152 5.04

5.05 ADMINISTRATIVE & GENERAL 344,705 0 2,406,381,258 5.05

5.06 OTHER ADMINISTRATIVE AND GENERAL 1,191,816 0 0 -70,740,618 672,840,154 5.06

6.00 MAINTENANCE & REPAIRS 1,071,774 0 0 0 27,197,530 6.00


8.00 LAUNDRY & LINEN SERVICE 3,383 0 0 0 3,471,910 8.00

9.00 HOUSEKEEPING 646,899 0 0 0 11,330,253 9.00

10.00 DIETARY 6,266,638 0 0 0 8,506,599 10.00

11.00 CAFETERIA 0 0 0 0 0 11.00

13.00 NURSING ADMINISTRATION 352,337 0 0 0 3,720,120 13.00

15.00 PHARMACY 265,694 0 0 0 11,120,435 15.00

16.00 MEDICAL RECORDS & LIBRARY 89,274 0 0 0 7,184,578 16.00

17.00 SOCIAL SERVICE 2,449 0 0 0 2,468,270 17.00


21.00 I&R SERVICES-SALARY & FRINGES APPRVD 0 0 0 0 15,989,261 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 309,916 0 0 0 12,886,559 22.00

23.00 PARAMEDIC 35,693 0 0 0 757,897 23.00

23.01 PASTORAL CARE 9,955 0 0 0 349,811 23.01

23.02 PHARMACY RESIDENCY 1,147 0 0 0 226,390 23.02


30.00 ADULTS & PEDIATRICS 8,061,393 266,254,294 270,347,342 0 120,445,517 30.00

31.00 INTENSIVE CARE UNIT 4,101,126 113,899,016 113,899,016 0 40,638,700 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 915,226 31,990,650 31,990,650 0 11,101,997 31.01




40.00 SUBPROVIDER - IPF 79,589 15,512,871 15,512,871 0 5,778,622 40.00

41.00 SUBPROVIDER - IRF 327,463 15,763,100 15,763,100 0 7,663,147 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 397,379 13,626,360 13,626,360 0 5,436,247 43.00


50.00 OPERATING ROOM 60,029,350 177,226,926 262,277,988 0 51,403,571 50.00

51.00 RECOVERY ROOM 69,516 21,342,611 41,782,683 0 5,437,424 51.00

52.00 DELIVERY ROOM & LABOR ROOM 1,358,204 27,243,441 36,563,633 0 10,482,824 52.00

53.00 ANESTHESIOLOGY 1,212,430 32,493,551 51,326,787 0 2,504,451 53.00

54.00 RADIOLOGY-DIAGNOSTIC 15,620,706 150,353,414 295,648,937 0 42,100,096 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 7,950,941 138,809,733 197,587,190 0 26,866,869 60.00

60.01 BLOOD LABORATORY 1,227,299 27,052,251 32,253,237 0 4,147,147 60.01


65.00 RESPIRATORY THERAPY 5,067,105 114,250,935 118,932,516 0 18,065,755 65.00

66.00 PHYSICAL THERAPY 10,879,566 29,364,156 45,988,420 0 6,116,148 66.00

67.00 OCCUPATIONAL THERAPY 319,476 12,322,335 19,532,239 0 6,226,606 67.00


69.00 ELECTROCARDIOLOGY 230,381 32,028,950 52,338,067 0 5,915,749 69.00

70.00 ELECTROENCEPHALOGRAPHY 13,591 1,770,341 3,112,038 0 646,024 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 95,174,520 114,499,615 0 71,218,709 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 0 134,495,162 164,409,196 0 47,299,203 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 250,616,170 305,958,243 0 37,514,920 73.00

74.00 RENAL DIALYSIS 334,892 8,118,238 8,128,811 0 2,487,514 74.00

76.00 DEV EVALUATION 45,896 1,402,794 3,264,573 0 1,478,094 76.00

76.97 CARDIAC REHABILITATION 19,059 1,219,387 3,035,990 0 1,059,428 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 367,877 123,893 6,266,578 0 2,389,014 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 2,825,819 78,166,053 182,335,178 0 27,772,812 91.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description PURCHASING

RECEIVING AND

STORES

(SUPPLIES

EXPENSE)

ADMITTING

(INPATIENT

CHARGES)

ADMINISTRATIVE

& GENERAL

(GROSS

CHARGES)

Reconciliation OTHER

ADMINISTRATIVE

AND GENERAL

(ACCUM.

COST)

5.03 5.04 5.05 5A.06 5.06



99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 132,100,753 1,790,621,152 2,406,381,258 -70,740,618 667,406,201 118.00



190.01 OTHER NONREIMB 166,397 0 0 0 5,433,392 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 Cost to be allocated (per Wkst. B, Part I) 4,636,834 2,013,607 16,037,487 70,740,618 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 0.035057 0.001125 0.006665 0.105137 203.00

204.00 Cost to be allocated (per Wkst. B, Part II) 1,522,483 29,043 139,563 3,598,729 204.00

205.00 Unit cost multiplier (Wkst. B, Part II) 0.011511 0.000016 0.000058 0.005349 205.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description MAINTENANCE &

REPAIRS

(SQUARE

FEET)

OPERATION OF

PLANT

(SQUARE

FEET)

LAUNDRY &

LINEN SERVICE

(POUNDS)

HOUSEKEEPING

(HSK HOURS)

DIETARY

(MEALS)

6.00 7.00 8.00 9.00 10.00








5.04 ADMITTING 5.04



6.00 MAINTENANCE & REPAIRS 723,991 6.00

7.00 OPERATION OF PLANT 0 723,991 7.00

8.00 LAUNDRY & LINEN SERVICE 1,891 1,891 4,646,040 8.00

9.00 HOUSEKEEPING 8,061 8,061 0 104,693 9.00

10.00 DIETARY 26,270 26,270 0 4,898 1,541,687 10.00

11.00 CAFETERIA 0 0 0 0 745,460 11.00

13.00 NURSING ADMINISTRATION 5,700 5,700 0 1,175 0 13.00

15.00 PHARMACY 10,062 10,062 0 1,167 0 15.00

16.00 MEDICAL RECORDS & LIBRARY 5,714 5,714 0 849 0 16.00

17.00 SOCIAL SERVICE 1,177 1,177 0 150 0 17.00



22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 13,959 13,959 0 1,081 0 22.00

23.00 PARAMEDIC 1,318 1,318 13,079 775 0 23.00

23.01 PASTORAL CARE 718 718 0 82 0 23.01



30.00 ADULTS & PEDIATRICS 239,917 239,917 2,371,689 17,970 587,478 30.00

31.00 INTENSIVE CARE UNIT 56,138 56,138 533,748 7,340 117,985 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 3,459 3,459 55,757 251 0 31.01




40.00 SUBPROVIDER - IPF 15,566 15,566 68,202 1,413 39,335 40.00

41.00 SUBPROVIDER - IRF 15,252 15,252 91,377 1,115 51,429 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 4,839 4,839 35,757 806 0 43.00


50.00 OPERATING ROOM 94,663 94,663 133,955 3,968 0 50.00

51.00 RECOVERY ROOM 8,846 8,846 0 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 25,810 25,810 104,431 259 0 52.00

53.00 ANESTHESIOLOGY 1,169 1,169 0 52 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 70,240 70,240 609,461 14,916 0 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 20,998 20,998 32,410 3,656 0 60.00

60.01 BLOOD LABORATORY 2,209 2,209 0 221 0 60.01


65.00 RESPIRATORY THERAPY 3,466 3,466 0 1,182 0 65.00

66.00 PHYSICAL THERAPY 7,062 7,062 110,090 1,822 0 66.00

67.00 OCCUPATIONAL THERAPY 5,336 5,336 0 2,604 0 67.00


69.00 ELECTROCARDIOLOGY 6,621 6,621 45,096 1,101 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 104 104 35,527 257 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 12,894 12,894 0 6,434 0 71.00




74.00 RENAL DIALYSIS 3,355 3,355 0 147 0 74.00

76.00 DEV EVALUATION 4,630 4,630 0 620 0 76.00





90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 7,006 7,006 34,101 1,988 0 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 35,259 35,259 308,299 12,760 0 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description MAINTENANCE &

REPAIRS

(SQUARE

FEET)

OPERATION OF

PLANT

(SQUARE

FEET)

LAUNDRY &

LINEN SERVICE

(POUNDS)

HOUSEKEEPING

(HSK HOURS)

DIETARY

(MEALS)

6.00 7.00 8.00 9.00 10.00


99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 721,234 721,234 4,582,979 91,062 1,541,687 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 2,076 2,076 0 400 0 190.00

190.01 OTHER NONREIMB 681 681 63,061 13,231 0 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 Cost to be allocated (per Wkst. B, Part I) 30,056,997 0 3,915,442 12,856,140 11,093,042 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 41.515705 0.000000 0.842748 122.798468 7.195392 203.00

204.00 Cost to be allocated (per Wkst. B, Part II) 5,053,595 0 34,909 152,377 375,285 204.00

205.00 Unit cost multiplier (Wkst. B, Part II) 6.980190 0.000000 0.007514 1.455465 0.243425 205.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description CAFETERIA

(FTE'S)

NURSING

ADMINISTRATION

(NURSING

HOURS)

PHARMACY

(DRUGS)

MEDICAL

RECORDS &

LIBRARY

(MR TIME)

SOCIAL SERVICE

(SS TIME)

11.00 13.00 15.00 16.00 17.00








5.04 ADMITTING 5.04







10.00 DIETARY 10.00

11.00 CAFETERIA 3,803 11.00

13.00 NURSING ADMINISTRATION 26 6,247,112 13.00

15.00 PHARMACY 99 0 2,687,490 15.00

16.00 MEDICAL RECORDS & LIBRARY 65 1,251 0 48,616 16.00

17.00 SOCIAL SERVICE 28 1,673 0 37 38,515 17.00




23.00 PARAMEDIC 8 33 914 0 0 23.00

23.01 PASTORAL CARE 4 0 0 0 0 23.01



30.00 ADULTS & PEDIATRICS 1,290 2,888,919 675,109 16,801 30,160 30.00

31.00 INTENSIVE CARE UNIT 359 889,217 392,208 71 6,057 31.00





40.00 SUBPROVIDER - IPF 58 152,913 1,229 2,296 0 40.00

41.00 SUBPROVIDER - IRF 82 169,562 12,564 2,427 0 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 48 131,225 28,733 574 0 43.00


50.00 OPERATING ROOM 350 545,032 589,108 5,845 0 50.00

51.00 RECOVERY ROOM 47 69,603 1,979 244 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 101 259,880 81,462 384 0 52.00

53.00 ANESTHESIOLOGY 14 25,818 110,907 161 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 271 51,925 89,037 5,030 0 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 1 0 0 1,773 0 60.00

60.01 BLOOD LABORATORY 0 0 0 118 0 60.01


65.00 RESPIRATORY THERAPY 185 8,520 1,266 591 0 65.00

66.00 PHYSICAL THERAPY 65 5,616 14,942 426 0 66.00

67.00 OCCUPATIONAL THERAPY 66 5,937 1,459 272 0 67.00


69.00 ELECTROCARDIOLOGY 53 119,695 16,022 2,931 0 69.00






74.00 RENAL DIALYSIS 17 38,476 2,755 16 0 74.00

76.00 DEV EVALUATION 14 0 0 0 0 76.00

76.97 CARDIAC REHABILITATION 10 28,014 401 0 0 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 20 36,428 56,066 7 0 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 237 559,762 530,029 4,936 0 91.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description CAFETERIA

(FTE'S)

NURSING

ADMINISTRATION

(NURSING

HOURS)

PHARMACY

(DRUGS)

MEDICAL

RECORDS &

LIBRARY

(MR TIME)

SOCIAL SERVICE

(SS TIME)

11.00 13.00 15.00 16.00 17.00



99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 3,771 6,247,112 2,686,351 48,616 38,515 118.00



190.01 OTHER NONREIMB 32 0 1,139 0 0 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 Cost to be allocated (per Wkst. B, Part I) 5,363,876 4,528,841 12,990,274 8,374,005 2,842,139 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 1,410.432816 0.724950 4.833608 172.247922 73.793042 203.00

204.00 Cost to be allocated (per Wkst. B, Part II) 181,464 238,273 400,762 142,819 23,715 204.00

205.00 Unit cost multiplier (Wkst. B, Part II) 47.716014 0.038141 0.149121 2.937695 0.615734 205.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


INTERNS & RESIDENTS

Cost Center Description Reconciliation NONPHYSICIAN

ANESTHETISTS

(ACCUM.

COST)

SERVICES-SALAR

Y & FRINGES

(IR TIME)

SERVICES-OTHER

PRGM COSTS

(IR TIME)

Reconciliation

19A 19.00 21.00 22.00 23A








5.04 ADMITTING 5.04







10.00 DIETARY 10.00






19.00 NONPHYSICIAN ANESTHETISTS 0 743,580,772 19.00

21.00 I&R SERVICES-SALARY & FRINGES APPRVD 0 21,422 21.00

22.00 I&R SERVICES-OTHER PRGM COSTS APPRVD 0 21,422 22.00

23.00 PARAMEDIC 0 -1,014,214 23.00

23.01 PASTORAL CARE 0 0 23.01

23.02 PHARMACY RESIDENCY 0 0 23.02


30.00 ADULTS & PEDIATRICS 0 11,545 11,545 0 30.00

31.00 INTENSIVE CARE UNIT 0 2,317 2,317 0 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 0 880 880 0 31.01




40.00 SUBPROVIDER - IPF 0 0 0 0 40.00

41.00 SUBPROVIDER - IRF 0 0 0 0 41.00

42.00 SUBPROVIDER 0 0 0 0 42.00

43.00 NURSERY 0 0 0 0 43.00


50.00 OPERATING ROOM 0 66,081,221 2,366 2,366 0 50.00

51.00 RECOVERY ROOM 0 6,544,689 0 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0 13,567,043 0 0 0 52.00

53.00 ANESTHESIOLOGY 0 3,424,955 393 393 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0 53,504,368 0 0 0 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 31,346,388 0 0 0 60.00

60.01 BLOOD LABORATORY 0 4,722,337 0 0 0 60.01


65.00 RESPIRATORY THERAPY 0 20,629,200 0 0 0 65.00

66.00 PHYSICAL THERAPY 0 7,610,233 0 0 0 66.00

67.00 OCCUPATIONAL THERAPY 0 7,573,844 0 0 0 67.00


69.00 ELECTROCARDIOLOGY 0 7,729,623 365 365 0 69.00


71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 80,031,819 0 0 0 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 0 52,272,099 0 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 41,553,001 0 0 0 73.00

74.00 RENAL DIALYSIS 0 2,974,323 0 0 0 74.00

76.00 DEV EVALUATION 0 1,921,595 0 0 0 76.00

76.97 CARDIAC REHABILITATION 0 1,268,690 0 0 0 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 3,530,733 0 0 0 90.03

90.04 OTHER 0 0 0 0 0 90.04


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


INTERNS & RESIDENTS

Cost Center Description Reconciliation NONPHYSICIAN

ANESTHETISTS

(ACCUM.

COST)

SERVICES-SALAR

Y & FRINGES

(IR TIME)

SERVICES-OTHER

PRGM COSTS

(IR TIME)

Reconciliation

19A 19.00 21.00 22.00 23A

91.00 EMERGENCY 0 38,135,530 3,556 3,556 0 91.00



99.10 CORF 0 0 0 0 0 99.10





118.00 SUBTOTALS (SUM OF LINES 1-117) 0 735,683,400 21,422 21,422 -1,014,214 118.00



190.01 OTHER NONREIMB 0 7,761,446 0 0 0 190.01

190.02 OTHER 0 0 0 0 0 190.02



202.00 Cost to be allocated (per Wkst. B, Part I) 0 17,670,324 15,166,504 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 0.000000 824.868080 707.987303 203.00

204.00 Cost to be allocated (per Wkst. B, Part II) 0 86,237 183,190 204.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description PARAMEDIC

(ACCUM.

COST)

PASTORAL CARE

(DAYS)

Reconciliation PHARMACY

RESIDENCY

(ACCUM.

COST)

23.00 23.01 23A.02 23.02








5.04 ADMITTING 5.04







10.00 DIETARY 10.00









23.00 PARAMEDIC 742,566,558 23.00

23.01 PASTORAL CARE 432,108 216,978 23.01

23.02 PHARMACY RESIDENCY 256,576 0 -256,926 743,323,846 23.02


30.00 ADULTS & PEDIATRICS 181,495,251 143,199 0 182,028,611 30.00

31.00 INTENSIVE CARE UNIT 56,499,627 28,759 0 56,634,156 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 15,241,700 10,910 0 15,284,277 31.01




40.00 SUBPROVIDER - IPF 8,140,505 9,588 0 8,170,745 40.00

41.00 SUBPROVIDER - IRF 10,403,359 12,536 0 10,442,569 41.00

42.00 SUBPROVIDER 0 0 0 0 42.00

43.00 NURSERY 6,738,389 11,986 0 6,771,497 43.00


50.00 OPERATING ROOM 69,707,957 0 0 69,803,178 50.00

51.00 RECOVERY ROOM 6,544,689 0 0 6,553,629 51.00

52.00 DELIVERY ROOM & LABOR ROOM 13,567,043 0 0 13,585,576 52.00

53.00 ANESTHESIOLOGY 4,027,367 0 0 4,032,868 53.00

54.00 RADIOLOGY-DIAGNOSTIC 53,504,368 0 0 53,577,455 54.00

57.00 CT SCAN 0 0 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0 0 0 0 59.00

60.00 LABORATORY 31,346,388 0 0 31,389,207 60.00

60.01 BLOOD LABORATORY 4,722,337 0 0 4,728,788 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 0 0 62.00

65.00 RESPIRATORY THERAPY 20,629,200 0 0 20,657,379 65.00

66.00 PHYSICAL THERAPY 7,610,233 0 0 7,620,629 66.00

67.00 OCCUPATIONAL THERAPY 7,573,844 0 0 7,584,190 67.00

68.00 SPEECH PATHOLOGY 0 0 0 0 68.00

69.00 ELECTROCARDIOLOGY 8,289,115 0 0 8,300,438 69.00

70.00 ELECTROENCEPHALOGRAPHY 800,506 0 0 801,599 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 80,031,819 0 0 80,141,142 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 0 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 52,272,099 0 0 52,343,503 72.00

73.00 DRUGS CHARGED TO PATIENTS 41,553,001 0 0 41,609,762 73.00

74.00 RENAL DIALYSIS 2,974,323 0 0 2,978,386 74.00

76.00 DEV EVALUATION 1,921,595 0 0 1,924,220 76.00

76.97 CARDIAC REHABILITATION 1,268,690 0 0 1,270,423 76.97




90.00 CLINIC 0 0 0 0 90.00

90.01 FAMILY PRACTICES 0 0 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 0 0 90.02

90.03 AMBULATORY CARE 3,530,733 0 0 3,535,556 90.03

90.04 OTHER 0 0 0 0 90.04

91.00 EMERGENCY 43,586,364 0 0 43,645,903 91.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet B-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Cost Center Description PARAMEDIC

(ACCUM.

COST)

PASTORAL CARE

(DAYS)

Reconciliation PHARMACY

RESIDENCY

(ACCUM.

COST)

23.00 23.01 23A.02 23.02


99.10 CORF 0 0 0 0 99.10


109.00 PANCREAS ACQUISITION 0 0 0 0 109.00

110.00 INTESTINAL ACQUISITION 0 0 0 0 110.00

111.00 ISLET ACQUISITION 0 0 0 0 111.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 734,669,186 216,978 -256,926 735,415,686 118.00


190.00 GIFT, FLOWER, COFFEE SHOP & CANTEEN 135,926 0 0 136,112 190.00

190.01 OTHER NONREIMB 7,761,446 0 0 7,772,048 190.01

190.02 OTHER 0 0 0 0 190.02



202.00 Cost to be allocated (per Wkst. B, Part I) 1,014,214 432,698 256,926 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 0.001366 1.994202 0.000346 203.00

204.00 Cost to be allocated (per Wkst. B, Part II) 110,292 9,484 2,705 204.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet C

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208COMPUTATION OF RATIO OF COSTS TO CHARGES

Title XVIII Hospital PPS

Costs

Cost Center Description Total Cost

(from Wkst. B,

Part I, col.

26)

Therapy Limit

Adj.

Total Costs RCE

Disallowance

Total Costs

1.00 2.00 3.00 4.00 5.00


30.00 ADULTS & PEDIATRICS 164,394,514 164,394,514 0 164,394,514 30.00

31.00 INTENSIVE CARE UNIT 53,102,125 53,102,125 0 53,102,125 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 13,940,652 13,940,652 0 13,940,652 31.01




40.00 SUBPROVIDER - IPF 8,173,572 8,173,572 0 8,173,572 40.00

41.00 SUBPROVIDER - IRF 10,446,182 10,446,182 0 10,446,182 41.00

42.00 SUBPROVIDER 0 0 0 0 42.00

43.00 NURSERY 6,773,840 6,773,840 0 6,773,840 43.00


50.00 OPERATING ROOM 66,200,594 66,200,594 0 66,200,594 50.00

51.00 RECOVERY ROOM 6,555,897 6,555,897 0 6,555,897 51.00

52.00 DELIVERY ROOM & LABOR ROOM 13,590,277 13,590,277 0 13,590,277 52.00

53.00 ANESTHESIOLOGY 3,431,851 3,431,851 0 3,431,851 53.00

54.00 RADIOLOGY-DIAGNOSTIC 53,595,993 53,595,993 0 53,595,993 54.00

57.00 CT SCAN 0 0 0 0 57.00



60.00 LABORATORY 31,400,068 31,400,068 0 31,400,068 60.00

60.01 BLOOD LABORATORY 4,730,424 4,730,424 0 4,730,424 60.01


65.00 RESPIRATORY THERAPY 20,664,526 0 20,664,526 0 20,664,526 65.00

66.00 PHYSICAL THERAPY 7,623,266 0 7,623,266 0 7,623,266 66.00

67.00 OCCUPATIONAL THERAPY 7,586,814 0 7,586,814 0 7,586,814 67.00


69.00 ELECTROCARDIOLOGY 7,743,818 7,743,818 0 7,743,818 69.00

70.00 ELECTROENCEPHALOGRAPHY 801,876 801,876 0 801,876 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 80,168,871 80,168,871 0 80,168,871 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 52,361,614 52,361,614 0 52,361,614 72.00

73.00 DRUGS CHARGED TO PATIENTS 41,624,159 41,624,159 0 41,624,159 73.00

74.00 RENAL DIALYSIS 2,979,417 2,979,417 0 2,979,417 74.00

76.00 DEV EVALUATION 1,924,886 1,924,886 0 1,924,886 76.00

76.97 CARDIAC REHABILITATION 1,270,863 1,270,863 0 1,270,863 76.97




90.00 CLINIC 0 0 0 0 90.00



90.03 AMBULATORY CARE 3,536,779 3,536,779 0 3,536,779 90.03

90.04 OTHER 0 0 0 0 90.04

91.00 EMERGENCY 38,210,170 38,210,170 0 38,210,170 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 4,655,023 4,655,023 4,655,023 92.00


99.10 CORF 0 0 0 99.10





200.00 Subtotal (see instructions) 707,488,071 0 707,488,071 0 707,488,071 200.00

201.00 Less Observation Beds 4,655,023 4,655,023 4,655,023 201.00

202.00 Total (see instructions) 702,833,048 0 702,833,048 0 702,833,048 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet C

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Charges

Cost Center Description Inpatient Outpatient Total (col. 6

+ col. 7)

Cost or Other

Ratio

TEFRA

Inpatient

Ratio

6.00 7.00 8.00 9.00 10.00


30.00 ADULTS & PEDIATRICS 264,646,130 264,646,130 30.00

31.00 INTENSIVE CARE UNIT 113,899,016 113,899,016 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 31,990,650 31,990,650 31.01




40.00 SUBPROVIDER - IPF 15,512,871 15,512,871 40.00

41.00 SUBPROVIDER - IRF 15,763,100 15,763,100 41.00


43.00 NURSERY 13,626,360 13,626,360 43.00


50.00 OPERATING ROOM 177,226,926 85,051,062 262,277,988 0.252406 0.000000 50.00

51.00 RECOVERY ROOM 21,342,611 20,440,072 41,782,683 0.156905 0.000000 51.00

52.00 DELIVERY ROOM & LABOR ROOM 27,243,441 9,320,192 36,563,633 0.371688 0.000000 52.00

53.00 ANESTHESIOLOGY 32,493,551 18,833,236 51,326,787 0.066863 0.000000 53.00

54.00 RADIOLOGY-DIAGNOSTIC 150,353,414 145,295,523 295,648,937 0.181283 0.000000 54.00

57.00 CT SCAN 0 0 0 0.000000 0.000000 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 0 0.000000 0.000000 58.00

59.00 CARDIAC CATHETERIZATION 0 0 0 0.000000 0.000000 59.00

60.00 LABORATORY 138,809,733 58,777,457 197,587,190 0.158918 0.000000 60.00

60.01 BLOOD LABORATORY 27,052,251 5,200,986 32,253,237 0.146665 0.000000 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 0 0.000000 0.000000 62.00

65.00 RESPIRATORY THERAPY 114,250,935 4,681,581 118,932,516 0.173750 0.000000 65.00

66.00 PHYSICAL THERAPY 29,364,156 16,624,264 45,988,420 0.165765 0.000000 66.00

67.00 OCCUPATIONAL THERAPY 12,322,335 7,209,904 19,532,239 0.388425 0.000000 67.00

68.00 SPEECH PATHOLOGY 0 0 0 0.000000 0.000000 68.00

69.00 ELECTROCARDIOLOGY 32,028,950 20,309,117 52,338,067 0.147958 0.000000 69.00

70.00 ELECTROENCEPHALOGRAPHY 1,770,341 1,341,697 3,112,038 0.257669 0.000000 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 95,174,520 19,325,095 114,499,615 0.700167 0.000000 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 0 0.000000 0.000000 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 134,495,162 29,914,034 164,409,196 0.318483 0.000000 72.00

73.00 DRUGS CHARGED TO PATIENTS 250,616,170 55,342,073 305,958,243 0.136045 0.000000 73.00

74.00 RENAL DIALYSIS 8,118,238 10,573 8,128,811 0.366526 0.000000 74.00

76.00 DEV EVALUATION 1,402,794 1,861,779 3,264,573 0.589629 0.000000 76.00

76.97 CARDIAC REHABILITATION 1,219,387 1,816,603 3,035,990 0.418599 0.000000 76.97




90.00 CLINIC 0 0 0 0.000000 0.000000 90.00

90.01 FAMILY PRACTICES 0 0 0 0.000000 0.000000 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 0 0.000000 0.000000 90.02

90.03 AMBULATORY CARE 123,893 6,142,685 6,266,578 0.564388 0.000000 90.03

90.04 OTHER 0 0 0 0.000000 0.000000 90.04

91.00 EMERGENCY 78,166,053 104,169,125 182,335,178 0.209560 0.000000 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 1,608,164 4,093,048 5,701,212 0.816497 0.000000 92.00


99.10 CORF 0 0 0 99.10





200.00 Subtotal (see instructions) 1,790,621,152 615,760,106 2,406,381,258 200.00

201.00 Less Observation Beds 201.00

202.00 Total (see instructions) 1,790,621,152 615,760,106 2,406,381,258 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet C

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Cost Center Description PPS Inpatient

Ratio

11.00


30.00 ADULTS & PEDIATRICS 30.00









43.00 NURSERY 43.00


50.00 OPERATING ROOM 0.252406 50.00

51.00 RECOVERY ROOM 0.156905 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0.371688 52.00

53.00 ANESTHESIOLOGY 0.066863 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.181283 54.00

57.00 CT SCAN 0.000000 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0.000000 58.00

59.00 CARDIAC CATHETERIZATION 0.000000 59.00

60.00 LABORATORY 0.158918 60.00

60.01 BLOOD LABORATORY 0.146665 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0.000000 62.00

65.00 RESPIRATORY THERAPY 0.173750 65.00

66.00 PHYSICAL THERAPY 0.165765 66.00

67.00 OCCUPATIONAL THERAPY 0.388425 67.00

68.00 SPEECH PATHOLOGY 0.000000 68.00

69.00 ELECTROCARDIOLOGY 0.147958 69.00

70.00 ELECTROENCEPHALOGRAPHY 0.257669 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.700167 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0.000000 71.30


73.00 DRUGS CHARGED TO PATIENTS 0.136045 73.00

74.00 RENAL DIALYSIS 0.366526 74.00

76.00 DEV EVALUATION 0.589629 76.00

76.97 CARDIAC REHABILITATION 0.418599 76.97


88.00 RURAL HEALTH CLINIC 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 89.00

90.00 CLINIC 0.000000 90.00

90.01 FAMILY PRACTICES 0.000000 90.01

90.02 WOMEN'S HEALTH CENTER 0.000000 90.02

90.03 AMBULATORY CARE 0.564388 90.03

90.04 OTHER 0.000000 90.04

91.00 EMERGENCY 0.209560 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0.816497 92.00


99.10 CORF 99.10


109.00 PANCREAS ACQUISITION 109.00

110.00 INTESTINAL ACQUISITION 110.00

111.00 ISLET ACQUISITION 111.00

200.00 Subtotal (see instructions) 200.00


202.00 Total (see instructions) 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet C

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Title XIX Hospital Cost

Costs

Cost Center Description Total Cost

(from Wkst. B,

Part I, col.

26)

Therapy Limit

Adj.

Total Costs RCE

Disallowance

Total Costs

1.00 2.00 3.00 4.00 5.00


30.00 ADULTS & PEDIATRICS 164,394,514 164,394,514 0 0 30.00

31.00 INTENSIVE CARE UNIT 53,102,125 53,102,125 0 0 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 13,940,652 13,940,652 0 0 31.01




40.00 SUBPROVIDER - IPF 8,173,572 8,173,572 0 0 40.00

41.00 SUBPROVIDER - IRF 10,446,182 10,446,182 0 0 41.00

42.00 SUBPROVIDER 0 0 0 0 42.00

43.00 NURSERY 6,773,840 6,773,840 0 0 43.00


50.00 OPERATING ROOM 66,200,594 66,200,594 0 0 50.00

51.00 RECOVERY ROOM 6,555,897 6,555,897 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 13,590,277 13,590,277 0 0 52.00

53.00 ANESTHESIOLOGY 3,431,851 3,431,851 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 53,595,993 53,595,993 0 0 54.00

57.00 CT SCAN 0 0 0 0 57.00



60.00 LABORATORY 31,400,068 31,400,068 0 0 60.00

60.01 BLOOD LABORATORY 4,730,424 4,730,424 0 0 60.01


65.00 RESPIRATORY THERAPY 20,664,526 0 20,664,526 0 0 65.00

66.00 PHYSICAL THERAPY 7,623,266 0 7,623,266 0 0 66.00

67.00 OCCUPATIONAL THERAPY 7,586,814 0 7,586,814 0 0 67.00


69.00 ELECTROCARDIOLOGY 7,743,818 7,743,818 0 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 801,876 801,876 0 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 80,168,871 80,168,871 0 0 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 52,361,614 52,361,614 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 41,624,159 41,624,159 0 0 73.00

74.00 RENAL DIALYSIS 2,979,417 2,979,417 0 0 74.00

76.00 DEV EVALUATION 1,924,886 1,924,886 0 0 76.00

76.97 CARDIAC REHABILITATION 1,270,863 1,270,863 0 0 76.97




90.00 CLINIC 0 0 0 0 90.00



90.03 AMBULATORY CARE 3,536,779 3,536,779 0 0 90.03

90.04 OTHER 0 0 0 0 90.04

91.00 EMERGENCY 38,210,170 38,210,170 0 0 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 4,655,023 4,655,023 0 92.00


99.10 CORF 0 0 0 99.10





200.00 Subtotal (see instructions) 707,488,071 0 707,488,071 0 0 200.00

201.00 Less Observation Beds 4,655,023 4,655,023 0 201.00

202.00 Total (see instructions) 702,833,048 0 702,833,048 0 0 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet C

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Charges

Cost Center Description Inpatient Outpatient Total (col. 6

+ col. 7)

Cost or Other

Ratio

TEFRA

Inpatient

Ratio

6.00 7.00 8.00 9.00 10.00


30.00 ADULTS & PEDIATRICS 264,646,130 264,646,130 30.00






40.00 SUBPROVIDER - IPF 15,512,871 15,512,871 40.00

41.00 SUBPROVIDER - IRF 15,763,100 15,763,100 41.00


43.00 NURSERY 13,626,360 13,626,360 43.00


50.00 OPERATING ROOM 177,226,926 85,051,062 262,277,988 0.252406 0.000000 50.00

51.00 RECOVERY ROOM 21,342,611 20,440,072 41,782,683 0.156905 0.000000 51.00

52.00 DELIVERY ROOM & LABOR ROOM 27,243,441 9,320,192 36,563,633 0.371688 0.000000 52.00

53.00 ANESTHESIOLOGY 32,493,551 18,833,236 51,326,787 0.066863 0.000000 53.00

54.00 RADIOLOGY-DIAGNOSTIC 150,353,414 145,295,523 295,648,937 0.181283 0.000000 54.00

57.00 CT SCAN 0 0 0 0.000000 0.000000 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 0 0.000000 0.000000 58.00

59.00 CARDIAC CATHETERIZATION 0 0 0 0.000000 0.000000 59.00

60.00 LABORATORY 138,809,733 58,777,457 197,587,190 0.158918 0.000000 60.00

60.01 BLOOD LABORATORY 27,052,251 5,200,986 32,253,237 0.146665 0.000000 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 0 0.000000 0.000000 62.00

65.00 RESPIRATORY THERAPY 114,250,935 4,681,581 118,932,516 0.173750 0.000000 65.00

66.00 PHYSICAL THERAPY 29,364,156 16,624,264 45,988,420 0.165765 0.000000 66.00

67.00 OCCUPATIONAL THERAPY 12,322,335 7,209,904 19,532,239 0.388425 0.000000 67.00

68.00 SPEECH PATHOLOGY 0 0 0 0.000000 0.000000 68.00

69.00 ELECTROCARDIOLOGY 32,028,950 20,309,117 52,338,067 0.147958 0.000000 69.00

70.00 ELECTROENCEPHALOGRAPHY 1,770,341 1,341,697 3,112,038 0.257669 0.000000 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 95,174,520 19,325,095 114,499,615 0.700167 0.000000 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 0 0.000000 0.000000 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 134,495,162 29,914,034 164,409,196 0.318483 0.000000 72.00

73.00 DRUGS CHARGED TO PATIENTS 250,616,170 55,342,073 305,958,243 0.136045 0.000000 73.00

74.00 RENAL DIALYSIS 8,118,238 10,573 8,128,811 0.366526 0.000000 74.00

76.00 DEV EVALUATION 1,402,794 1,861,779 3,264,573 0.589629 0.000000 76.00

76.97 CARDIAC REHABILITATION 1,219,387 1,816,603 3,035,990 0.418599 0.000000 76.97


88.00 RURAL HEALTH CLINIC 0 0 0 0.000000 0.000000 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0 0 0 0.000000 0.000000 89.00

90.00 CLINIC 0 0 0 0.000000 0.000000 90.00

90.01 FAMILY PRACTICES 0 0 0 0.000000 0.000000 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 0 0.000000 0.000000 90.02

90.03 AMBULATORY CARE 123,893 6,142,685 6,266,578 0.564388 0.000000 90.03

90.04 OTHER 0 0 0 0.000000 0.000000 90.04

91.00 EMERGENCY 78,166,053 104,169,125 182,335,178 0.209560 0.000000 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 1,608,164 4,093,048 5,701,212 0.816497 0.000000 92.00


99.10 CORF 0 0 0 99.10





200.00 Subtotal (see instructions) 1,790,621,152 615,760,106 2,406,381,258 200.00


202.00 Total (see instructions) 1,790,621,152 615,760,106 2,406,381,258 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet C

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Cost Center Description PPS Inpatient

Ratio

11.00


30.00 ADULTS & PEDIATRICS 30.00









43.00 NURSERY 43.00


50.00 OPERATING ROOM 0.000000 50.00

51.00 RECOVERY ROOM 0.000000 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0.000000 52.00

53.00 ANESTHESIOLOGY 0.000000 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.000000 54.00

57.00 CT SCAN 0.000000 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0.000000 58.00

59.00 CARDIAC CATHETERIZATION 0.000000 59.00

60.00 LABORATORY 0.000000 60.00

60.01 BLOOD LABORATORY 0.000000 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0.000000 62.00

65.00 RESPIRATORY THERAPY 0.000000 65.00

66.00 PHYSICAL THERAPY 0.000000 66.00

67.00 OCCUPATIONAL THERAPY 0.000000 67.00

68.00 SPEECH PATHOLOGY 0.000000 68.00

69.00 ELECTROCARDIOLOGY 0.000000 69.00

70.00 ELECTROENCEPHALOGRAPHY 0.000000 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.000000 71.00



73.00 DRUGS CHARGED TO PATIENTS 0.000000 73.00

74.00 RENAL DIALYSIS 0.000000 74.00

76.00 DEV EVALUATION 0.000000 76.00

76.97 CARDIAC REHABILITATION 0.000000 76.97




90.00 CLINIC 0.000000 90.00

90.01 FAMILY PRACTICES 0.000000 90.01

90.02 WOMEN'S HEALTH CENTER 0.000000 90.02

90.03 AMBULATORY CARE 0.000000 90.03

90.04 OTHER 0.000000 90.04

91.00 EMERGENCY 0.000000 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0.000000 92.00


99.10 CORF 99.10


109.00 PANCREAS ACQUISITION 109.00

110.00 INTESTINAL ACQUISITION 110.00

111.00 ISLET ACQUISITION 111.00

200.00 Subtotal (see instructions) 200.00


202.00 Total (see instructions) 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS


Cost Center Description Capital

Related Cost

(from Wkst. B,

Part II, col.

26)

Swing Bed

Adjustment

Reduced

Capital

Related Cost

(col. 1 - col.

2)

Total Patient

Days

Per Diem (col.

3 / col. 4)

1.00 2.00 3.00 4.00 5.00


30.00 ADULTS & PEDIATRICS 6,473,947 0 6,473,947 147,372 43.93 30.00

31.00 INTENSIVE CARE UNIT 1,690,102 1,690,102 28,759 58.77 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 930,379 930,379 10,910 85.28 31.01

32.00 CORONARY CARE UNIT 0 0 0 0.00 32.00

33.00 BURN INTENSIVE CARE UNIT 0 0 0 0.00 33.00

34.00 SURGICAL INTENSIVE CARE UNIT 0 0 0 0.00 34.00

40.00 SUBPROVIDER - IPF 221,940 0 221,940 9,588 23.15 40.00

41.00 SUBPROVIDER - IRF 264,639 0 264,639 12,536 21.11 41.00

42.00 SUBPROVIDER 0 0 0 0 0.00 42.00

43.00 NURSERY 467,832 467,832 11,986 39.03 43.00

200.00 Total (lines 30-199) 10,048,839 10,048,839 221,151 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS


Cost Center Description Inpatient

Program days

Inpatient

Program

Capital Cost

(col. 5 x col.

6)

6.00 7.00


30.00 ADULTS & PEDIATRICS 57,821 2,540,077 30.00

31.00 INTENSIVE CARE UNIT 11,908 699,833 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 0 0 31.01




40.00 SUBPROVIDER - IPF 4,494 104,036 40.00

41.00 SUBPROVIDER - IRF 7,087 149,607 41.00


43.00 NURSERY 0 0 43.00

200.00 Total (lines 30-199) 81,310 3,493,553 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS



Related Cost

(from Wkst. B,

Part II, col.

26)

Total Charges

(from Wkst. C,

Part I, col.

8)

Ratio of Cost

to Charges

(col. 1 ÷ col.

2)

Inpatient

Program

Charges

Capital Costs

(column 3 x

column 4)

1.00 2.00 3.00 4.00 5.00


50.00 OPERATING ROOM 8,101,845 262,277,988 0.030890 57,985,135 1,791,161 50.00

51.00 RECOVERY ROOM 105,144 41,782,683 0.002516 8,516,262 21,427 51.00

52.00 DELIVERY ROOM & LABOR ROOM 812,882 36,563,633 0.022232 152,275 3,385 52.00

53.00 ANESTHESIOLOGY 294,629 51,326,787 0.005740 10,064,192 57,768 53.00

54.00 RADIOLOGY-DIAGNOSTIC 9,828,856 295,648,937 0.033245 67,755,904 2,252,545 54.00

57.00 CT SCAN 0 0 0.000000 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 0.000000 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0 0 0.000000 0 0 59.00

60.00 LABORATORY 876,575 197,587,190 0.004436 56,925,131 252,520 60.00

60.01 BLOOD LABORATORY 58,754 32,253,237 0.001822 10,393,283 18,937 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 0.000000 0 0 62.00

65.00 RESPIRATORY THERAPY 806,398 118,932,516 0.006780 35,567,702 241,149 65.00

66.00 PHYSICAL THERAPY 331,476 45,988,420 0.007208 6,981,551 50,323 66.00

67.00 OCCUPATIONAL THERAPY 104,394 19,532,239 0.005345 153,708 822 67.00

68.00 SPEECH PATHOLOGY 0 0 0.000000 0 0 68.00

69.00 ELECTROCARDIOLOGY 746,822 52,338,067 0.014269 14,101,334 201,212 69.00

70.00 ELECTROENCEPHALOGRAPHY 119,072 3,112,038 0.038262 633,860 24,253 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 497,067 114,499,615 0.004341 37,432,492 162,494 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 0.000000 0 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 277,022 164,409,196 0.001685 56,452,999 95,123 72.00

73.00 DRUGS CHARGED TO PATIENTS 245,962 305,958,243 0.000804 91,486,330 73,555 73.00

74.00 RENAL DIALYSIS 488,250 8,128,811 0.060064 5,008,738 300,845 74.00

76.00 DEV EVALUATION 54,692 3,264,573 0.016753 4,300 72 76.00

76.97 CARDIAC REHABILITATION 24,140 3,035,990 0.007951 590,303 4,693 76.97


88.00 RURAL HEALTH CLINIC 0 0 0.000000 0 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0 0 0.000000 0 0 89.00

90.00 CLINIC 0 0 0.000000 0 0 90.00

90.01 FAMILY PRACTICES 0 0 0.000000 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 0.000000 0 0 90.02

90.03 AMBULATORY CARE 91,221 6,266,578 0.014557 70,806 1,031 90.03

90.04 OTHER 0 0 0.000000 0 0 90.04

91.00 EMERGENCY 1,929,163 182,335,178 0.010580 28,154,660 297,876 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 183,319 5,701,212 0.032154 681,975 21,928 92.00

200.00 Total (lines 50-199) 25,977,683 1,950,943,131 489,112,940 5,873,119 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS


Cost Center Description Nursing School Allied Health

Cost

All Other

Medical

Education Cost

Swing-Bed

Adjustment

Amount (see

instructions)

Total Costs

(sum of cols.

1 through 3,

minus col. 4)

1.00 2.00 3.00 4.00 5.00


30.00 ADULTS & PEDIATRICS 0 596,078 0 0 596,078 30.00

31.00 INTENSIVE CARE UNIT 0 154,124 0 154,124 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 0 47,865 0 47,865 31.01




40.00 SUBPROVIDER - IPF 0 33,067 0 0 33,067 40.00

41.00 SUBPROVIDER - IRF 0 42,823 0 0 42,823 41.00

42.00 SUBPROVIDER 0 0 0 0 0 42.00

43.00 NURSERY 0 35,451 0 35,451 43.00

200.00 Total (lines 30-199) 0 909,408 0 909,408 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS


Cost Center Description Total Patient

Days

Per Diem (col.

5 ÷ col. 6)

Inpatient

Program Days

Inpatient

Program

Pass-Through

Cost (col. 7 x

col. 8)

6.00 7.00 8.00 9.00


30.00 ADULTS & PEDIATRICS 147,372 4.04 57,821 233,597 30.00

31.00 INTENSIVE CARE UNIT 28,759 5.36 11,908 63,827 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 10,910 4.39 0 0 31.01

32.00 CORONARY CARE UNIT 0 0.00 0 0 32.00

33.00 BURN INTENSIVE CARE UNIT 0 0.00 0 0 33.00

34.00 SURGICAL INTENSIVE CARE UNIT 0 0.00 0 0 34.00

40.00 SUBPROVIDER - IPF 9,588 3.45 4,494 15,504 40.00

41.00 SUBPROVIDER - IRF 12,536 3.42 7,087 24,238 41.00

42.00 SUBPROVIDER 0 0.00 0 0 42.00

43.00 NURSERY 11,986 2.96 0 0 43.00

200.00 Total (lines 30-199) 221,151 81,310 337,166 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY SERVICE OTHER PASS

THROUGH COSTS


Cost Center Description Non Physician

Anesthetist

Cost

Nursing School Allied Health All Other

Medical

Education Cost

Total Cost

(sum of col 1

through col.

4)

1.00 2.00 3.00 4.00 5.00


50.00 OPERATING ROOM 0 0 119,373 0 119,373 50.00

51.00 RECOVERY ROOM 0 0 11,208 0 11,208 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0 0 23,234 0 23,234 52.00

53.00 ANESTHESIOLOGY 0 0 6,896 0 6,896 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0 0 91,625 0 91,625 54.00

57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 0 53,680 0 53,680 60.00

60.01 BLOOD LABORATORY 0 0 8,087 0 8,087 60.01


65.00 RESPIRATORY THERAPY 0 0 35,326 0 35,326 65.00

66.00 PHYSICAL THERAPY 0 0 13,033 0 13,033 66.00

67.00 OCCUPATIONAL THERAPY 0 0 12,970 0 12,970 67.00


69.00 ELECTROCARDIOLOGY 0 0 14,195 0 14,195 69.00

70.00 ELECTROENCEPHALOGRAPHY 0 0 1,370 0 1,370 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0 0 137,052 0 137,052 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 0 0 89,515 0 89,515 72.00

73.00 DRUGS CHARGED TO PATIENTS 0 0 71,158 0 71,158 73.00

74.00 RENAL DIALYSIS 0 0 5,094 0 5,094 74.00

76.00 DEV EVALUATION 0 0 3,291 0 3,291 76.00

76.97 CARDIAC REHABILITATION 0 0 2,173 0 2,173 76.97




90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 0 6,046 0 6,046 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 0 0 74,640 0 74,640 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0 0 16,879 0 16,879 92.00

200.00 Total (lines 50-199) 0 0 796,845 0 796,845 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


THROUGH COSTS


Cost Center Description Total

Outpatient

Cost (sum of

col. 2, 3 and

4)

Total Charges

(from Wkst. C,

Part I, col.

8)

Ratio of Cost

to Charges

(col. 5 ÷ col.

7)

Outpatient

Ratio of Cost

to Charges

(col. 6 ÷ col.

7)

Inpatient

Program

Charges

6.00 7.00 8.00 9.00 10.00


50.00 OPERATING ROOM 119,373 262,277,988 0.000455 0.000455 57,985,135 50.00

51.00 RECOVERY ROOM 11,208 41,782,683 0.000268 0.000268 8,516,262 51.00

52.00 DELIVERY ROOM & LABOR ROOM 23,234 36,563,633 0.000635 0.000635 152,275 52.00

53.00 ANESTHESIOLOGY 6,896 51,326,787 0.000134 0.000134 10,064,192 53.00

54.00 RADIOLOGY-DIAGNOSTIC 91,625 295,648,937 0.000310 0.000310 67,755,904 54.00

57.00 CT SCAN 0 0 0.000000 0.000000 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0 0 0.000000 0.000000 0 58.00

59.00 CARDIAC CATHETERIZATION 0 0 0.000000 0.000000 0 59.00

60.00 LABORATORY 53,680 197,587,190 0.000272 0.000272 56,925,131 60.00

60.01 BLOOD LABORATORY 8,087 32,253,237 0.000251 0.000251 10,393,283 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0 0 0.000000 0.000000 0 62.00

65.00 RESPIRATORY THERAPY 35,326 118,932,516 0.000297 0.000297 35,567,702 65.00

66.00 PHYSICAL THERAPY 13,033 45,988,420 0.000283 0.000283 6,981,551 66.00

67.00 OCCUPATIONAL THERAPY 12,970 19,532,239 0.000664 0.000664 153,708 67.00

68.00 SPEECH PATHOLOGY 0 0 0.000000 0.000000 0 68.00

69.00 ELECTROCARDIOLOGY 14,195 52,338,067 0.000271 0.000271 14,101,334 69.00

70.00 ELECTROENCEPHALOGRAPHY 1,370 3,112,038 0.000440 0.000440 633,860 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 137,052 114,499,615 0.001197 0.001197 37,432,492 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0 0 0.000000 0.000000 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 89,515 164,409,196 0.000544 0.000544 56,452,999 72.00

73.00 DRUGS CHARGED TO PATIENTS 71,158 305,958,243 0.000233 0.000233 91,486,330 73.00

74.00 RENAL DIALYSIS 5,094 8,128,811 0.000627 0.000627 5,008,738 74.00

76.00 DEV EVALUATION 3,291 3,264,573 0.001008 0.001008 4,300 76.00

76.97 CARDIAC REHABILITATION 2,173 3,035,990 0.000716 0.000716 590,303 76.97


88.00 RURAL HEALTH CLINIC 0 0 0.000000 0.000000 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0 0 0.000000 0.000000 0 89.00

90.00 CLINIC 0 0 0.000000 0.000000 0 90.00

90.01 FAMILY PRACTICES 0 0 0.000000 0.000000 0 90.01

90.02 WOMEN'S HEALTH CENTER 0 0 0.000000 0.000000 0 90.02

90.03 AMBULATORY CARE 6,046 6,266,578 0.000965 0.000965 70,806 90.03

90.04 OTHER 0 0 0.000000 0.000000 0 90.04

91.00 EMERGENCY 74,640 182,335,178 0.000409 0.000409 28,154,660 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 16,879 5,701,212 0.002961 0.002961 681,975 92.00

200.00 Total (lines 50-199) 796,845 1,950,943,131 489,112,940 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


THROUGH COSTS



Program

Pass-Through

Costs (col. 8

x col. 10)

Outpatient

Program

Charges

Outpatient

Program

Pass-Through

Costs (col. 9

x col. 12)

11.00 12.00 13.00


50.00 OPERATING ROOM 26,383 19,672,452 8,951 50.00

51.00 RECOVERY ROOM 2,282 4,816,344 1,291 51.00

52.00 DELIVERY ROOM & LABOR ROOM 97 82,866 53 52.00

53.00 ANESTHESIOLOGY 1,349 3,777,199 506 53.00

54.00 RADIOLOGY-DIAGNOSTIC 21,004 40,446,369 12,538 54.00

57.00 CT SCAN 0 0 0 57.00



60.00 LABORATORY 15,484 2,069,071 563 60.00

60.01 BLOOD LABORATORY 2,609 1,181,874 297 60.01


65.00 RESPIRATORY THERAPY 10,564 670,920 199 65.00

66.00 PHYSICAL THERAPY 1,976 412,780 117 66.00

67.00 OCCUPATIONAL THERAPY 102 562,346 373 67.00


69.00 ELECTROCARDIOLOGY 3,821 4,313,908 1,169 69.00

70.00 ELECTROENCEPHALOGRAPHY 279 78,417 35 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 44,807 5,627,689 6,736 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 30,710 11,113,423 6,046 72.00

73.00 DRUGS CHARGED TO PATIENTS 21,316 19,828,506 4,620 73.00

74.00 RENAL DIALYSIS 3,140 6,655 4 74.00

76.00 DEV EVALUATION 4 0 0 76.00

76.97 CARDIAC REHABILITATION 423 886,016 634 76.97




90.00 CLINIC 0 0 0 90.00



90.03 AMBULATORY CARE 68 2,056,573 1,985 90.03

90.04 OTHER 0 0 0 90.04

91.00 EMERGENCY 11,515 11,627,190 4,756 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 2,019 2,923,799 8,657 92.00

200.00 Total (lines 50-199) 199,952 132,154,397 59,530 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part V

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST


Charges

Cost Center Description Cost to Charge

Ratio From

Worksheet C,

Part I, col. 9

PPS Reimbursed

Services (see

instructions)

Cost

Reimbursed

Services

Subject To

Ded. & Coins.

(see

instructions)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see

instructions)

1.00 2.00 3.00 4.00


50.00 OPERATING ROOM 0.252406 19,672,452 0 0 50.00

51.00 RECOVERY ROOM 0.156905 4,816,344 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0.371688 82,866 0 0 52.00

53.00 ANESTHESIOLOGY 0.066863 3,777,199 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.181283 40,446,369 0 0 54.00

57.00 CT SCAN 0.000000 0 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0.000000 0 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0.000000 0 0 0 59.00

60.00 LABORATORY 0.158918 2,069,071 0 0 60.00

60.01 BLOOD LABORATORY 0.146665 1,181,874 0 0 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0.000000 0 0 0 62.00

65.00 RESPIRATORY THERAPY 0.173750 670,920 0 0 65.00

66.00 PHYSICAL THERAPY 0.165765 412,780 0 0 66.00

67.00 OCCUPATIONAL THERAPY 0.388425 562,346 0 0 67.00

68.00 SPEECH PATHOLOGY 0.000000 0 0 0 68.00

69.00 ELECTROCARDIOLOGY 0.147958 4,313,908 0 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 0.257669 78,417 0 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.700167 5,627,689 0 0 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0.000000 0 0 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 0.318483 11,113,423 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 0.136045 19,828,506 0 0 73.00

74.00 RENAL DIALYSIS 0.366526 6,655 0 0 74.00

76.00 DEV EVALUATION 0.589629 0 0 0 76.00

76.97 CARDIAC REHABILITATION 0.418599 886,016 0 0 76.97




90.00 CLINIC 0.000000 0 0 0 90.00

90.01 FAMILY PRACTICES 0.000000 0 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0.000000 0 0 0 90.02

90.03 AMBULATORY CARE 0.564388 2,056,573 0 0 90.03

90.04 OTHER 0.000000 0 0 0 90.04

91.00 EMERGENCY 0.209560 11,627,190 0 0 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0.816497 2,923,799 0 0 92.00

200.00 Subtotal (see instructions) 132,154,397 0 0 200.00

201.00 Less PBP Clinic Lab. Services-Program Only

Charges

0 0 201.00

202.00 Net Charges (line 200 +/- line 201) 132,154,397 0 0 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part V

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Costs

Cost Center Description PPS Services

(see

instructions)

Cost Services

Subject To

Ded. & Coins.

(see

instructions)

Cost Services

Not Subject To

Ded. & Coins.

(see

instructions)

5.00 6.00 7.00


50.00 OPERATING ROOM 4,965,445 0 0 50.00

51.00 RECOVERY ROOM 755,708 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 30,800 0 0 52.00

53.00 ANESTHESIOLOGY 252,555 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 7,332,239 0 0 54.00

57.00 CT SCAN 0 0 0 57.00



60.00 LABORATORY 328,813 0 0 60.00

60.01 BLOOD LABORATORY 173,340 0 0 60.01


65.00 RESPIRATORY THERAPY 116,572 0 0 65.00

66.00 PHYSICAL THERAPY 68,424 0 0 66.00

67.00 OCCUPATIONAL THERAPY 218,429 0 0 67.00


69.00 ELECTROCARDIOLOGY 638,277 0 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 20,206 0 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 3,940,322 0 0 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 3,539,436 0 0 72.00

73.00 DRUGS CHARGED TO PATIENTS 2,697,569 0 0 73.00

74.00 RENAL DIALYSIS 2,439 0 0 74.00


76.97 CARDIAC REHABILITATION 370,885 0 0 76.97




90.00 CLINIC 0 0 0 90.00



90.03 AMBULATORY CARE 1,160,705 0 0 90.03

90.04 OTHER 0 0 0 90.04

91.00 EMERGENCY 2,436,594 0 0 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 2,387,273 0 0 92.00

200.00 Subtotal (see instructions) 31,436,031 0 0 200.00


Charges

0 201.00

202.00 Net Charges (line 200 +/- line 201) 31,436,031 0 0 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208

Component CCN:14S208

APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS

Title XVIII Subprovider -

IPF

PPS


Related Cost

(from Wkst. B,

Part II, col.

26)

Total Charges

(from Wkst. C,

Part I, col.

8)

Ratio of Cost

to Charges

(col. 1 ÷ col.

2)

Inpatient

Program

Charges

Capital Costs

(column 3 x

column 4)

1.00 2.00 3.00 4.00 5.00


50.00 OPERATING ROOM 8,101,845 262,277,988 0.030890 1,804 56 50.00

51.00 RECOVERY ROOM 105,144 41,782,683 0.002516 751 2 51.00

52.00 DELIVERY ROOM & LABOR ROOM 812,882 36,563,633 0.022232 1,319 29 52.00

53.00 ANESTHESIOLOGY 294,629 51,326,787 0.005740 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 9,828,856 295,648,937 0.033245 307,648 10,228 54.00

57.00 CT SCAN 0 0 0.000000 0 0 57.00



60.00 LABORATORY 876,575 197,587,190 0.004436 798,842 3,544 60.00

60.01 BLOOD LABORATORY 58,754 32,253,237 0.001822 1,092 2 60.01


65.00 RESPIRATORY THERAPY 806,398 118,932,516 0.006780 244,967 1,661 65.00

66.00 PHYSICAL THERAPY 331,476 45,988,420 0.007208 87,318 629 66.00

67.00 OCCUPATIONAL THERAPY 104,394 19,532,239 0.005345 132,770 710 67.00


69.00 ELECTROCARDIOLOGY 746,822 52,338,067 0.014269 191,791 2,737 69.00

70.00 ELECTROENCEPHALOGRAPHY 119,072 3,112,038 0.038262 6,529 250 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 497,067 114,499,615 0.004341 45,209 196 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 277,022 164,409,196 0.001685 0 0 72.00


74.00 RENAL DIALYSIS 488,250 8,128,811 0.060064 59,662 3,584 74.00

76.00 DEV EVALUATION 54,692 3,264,573 0.016753 58 1 76.00

76.97 CARDIAC REHABILITATION 24,140 3,035,990 0.007951 0 0 76.97




90.00 CLINIC 0 0 0.000000 0 0 90.00



90.03 AMBULATORY CARE 91,221 6,266,578 0.014557 220 3 90.03

90.04 OTHER 0 0 0.000000 0 0 90.04

91.00 EMERGENCY 1,929,163 182,335,178 0.010580 593,097 6,275 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 183,319 5,701,212 0.032154 0 0 92.00

200.00 Total (lines 50-199) 25,977,683 1,950,943,131 3,979,698 31,118 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY SERVICE OTHER PASS

THROUGH COSTS


IPF

PPS


Anesthetist

Cost


Medical

Education Cost

Total Cost

(sum of col 1

through col.

4)

1.00 2.00 3.00 4.00 5.00


50.00 OPERATING ROOM 0 0 119,373 0 119,373 50.00

51.00 RECOVERY ROOM 0 0 11,208 0 11,208 51.00


53.00 ANESTHESIOLOGY 0 0 6,896 0 6,896 53.00


57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 0 53,680 0 53,680 60.00













74.00 RENAL DIALYSIS 0 0 5,094 0 5,094 74.00

76.00 DEV EVALUATION 0 0 3,291 0 3,291 76.00





90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 0 6,046 0 6,046 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 0 0 74,640 0 74,640 91.00


200.00 Total (lines 50-199) 0 0 796,845 0 796,845 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




THROUGH COSTS


IPF

PPS


Outpatient

Cost (sum of

col. 2, 3 and

4)

Total Charges

(from Wkst. C,

Part I, col.

8)

Ratio of Cost

to Charges

(col. 5 ÷ col.

7)

Outpatient

Ratio of Cost

to Charges

(col. 6 ÷ col.

7)

Inpatient

Program

Charges

6.00 7.00 8.00 9.00 10.00


50.00 OPERATING ROOM 119,373 262,277,988 0.000455 0.000455 1,804 50.00

51.00 RECOVERY ROOM 11,208 41,782,683 0.000268 0.000268 751 51.00

52.00 DELIVERY ROOM & LABOR ROOM 23,234 36,563,633 0.000635 0.000635 1,319 52.00

53.00 ANESTHESIOLOGY 6,896 51,326,787 0.000134 0.000134 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 91,625 295,648,937 0.000310 0.000310 307,648 54.00

57.00 CT SCAN 0 0 0.000000 0.000000 0 57.00



60.00 LABORATORY 53,680 197,587,190 0.000272 0.000272 798,842 60.00

60.01 BLOOD LABORATORY 8,087 32,253,237 0.000251 0.000251 1,092 60.01


65.00 RESPIRATORY THERAPY 35,326 118,932,516 0.000297 0.000297 244,967 65.00

66.00 PHYSICAL THERAPY 13,033 45,988,420 0.000283 0.000283 87,318 66.00

67.00 OCCUPATIONAL THERAPY 12,970 19,532,239 0.000664 0.000664 132,770 67.00


69.00 ELECTROCARDIOLOGY 14,195 52,338,067 0.000271 0.000271 191,791 69.00


71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 137,052 114,499,615 0.001197 0.001197 45,209 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 89,515 164,409,196 0.000544 0.000544 0 72.00


74.00 RENAL DIALYSIS 5,094 8,128,811 0.000627 0.000627 59,662 74.00

76.00 DEV EVALUATION 3,291 3,264,573 0.001008 0.001008 58 76.00

76.97 CARDIAC REHABILITATION 2,173 3,035,990 0.000716 0.000716 0 76.97




90.00 CLINIC 0 0 0.000000 0.000000 0 90.00



90.03 AMBULATORY CARE 6,046 6,266,578 0.000965 0.000965 220 90.03

90.04 OTHER 0 0 0.000000 0.000000 0 90.04

91.00 EMERGENCY 74,640 182,335,178 0.000409 0.000409 593,097 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 16,879 5,701,212 0.002961 0.002961 0 92.00

200.00 Total (lines 50-199) 796,845 1,950,943,131 3,979,698 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




THROUGH COSTS


IPF

PPS


Program

Pass-Through

Costs (col. 8

x col. 10)

Outpatient

Program

Charges

Outpatient

Program

Pass-Through

Costs (col. 9

x col. 12)

11.00 12.00 13.00


50.00 OPERATING ROOM 1 0 0 50.00

51.00 RECOVERY ROOM 0 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 1 0 0 52.00

53.00 ANESTHESIOLOGY 0 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 95 0 0 54.00

57.00 CT SCAN 0 0 0 57.00



60.00 LABORATORY 217 0 0 60.00

60.01 BLOOD LABORATORY 0 0 0 60.01


65.00 RESPIRATORY THERAPY 73 0 0 65.00

66.00 PHYSICAL THERAPY 25 0 0 66.00

67.00 OCCUPATIONAL THERAPY 88 0 0 67.00


69.00 ELECTROCARDIOLOGY 52 0 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 3 0 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 54 0 0 71.00



73.00 DRUGS CHARGED TO PATIENTS 351 0 0 73.00

74.00 RENAL DIALYSIS 37 0 0 74.00


76.97 CARDIAC REHABILITATION 0 0 0 76.97




90.00 CLINIC 0 0 0 90.00



90.03 AMBULATORY CARE 0 0 0 90.03

90.04 OTHER 0 0 0 90.04

91.00 EMERGENCY 243 0 0 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0 0 0 92.00

200.00 Total (lines 50-199) 1,240 0 0 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011


Component CCN:14T208

APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS


IRF

PPS


Related Cost

(from Wkst. B,

Part II, col.

26)

Total Charges

(from Wkst. C,

Part I, col.

8)

Ratio of Cost

to Charges

(col. 1 ÷ col.

2)

Inpatient

Program

Charges

Capital Costs

(column 3 x

column 4)

1.00 2.00 3.00 4.00 5.00


50.00 OPERATING ROOM 8,101,845 262,277,988 0.030890 133,279 4,117 50.00

51.00 RECOVERY ROOM 105,144 41,782,683 0.002516 34,284 86 51.00

52.00 DELIVERY ROOM & LABOR ROOM 812,882 36,563,633 0.022232 0 0 52.00

53.00 ANESTHESIOLOGY 294,629 51,326,787 0.005740 25,068 144 53.00

54.00 RADIOLOGY-DIAGNOSTIC 9,828,856 295,648,937 0.033245 718,289 23,880 54.00

57.00 CT SCAN 0 0 0.000000 0 0 57.00



60.00 LABORATORY 876,575 197,587,190 0.004436 1,228,160 5,448 60.00

60.01 BLOOD LABORATORY 58,754 32,253,237 0.001822 103,916 189 60.01


65.00 RESPIRATORY THERAPY 806,398 118,932,516 0.006780 619,874 4,203 65.00

66.00 PHYSICAL THERAPY 331,476 45,988,420 0.007208 6,315 46 66.00

67.00 OCCUPATIONAL THERAPY 104,394 19,532,239 0.005345 6,644,990 35,517 67.00


69.00 ELECTROCARDIOLOGY 746,822 52,338,067 0.014269 106,609 1,521 69.00

70.00 ELECTROENCEPHALOGRAPHY 119,072 3,112,038 0.038262 8,026 307 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 497,067 114,499,615 0.004341 629,838 2,734 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 277,022 164,409,196 0.001685 12,246 21 72.00


74.00 RENAL DIALYSIS 488,250 8,128,811 0.060064 287,612 17,275 74.00

76.00 DEV EVALUATION 54,692 3,264,573 0.016753 1,003 17 76.00

76.97 CARDIAC REHABILITATION 24,140 3,035,990 0.007951 0 0 76.97




90.00 CLINIC 0 0 0.000000 0 0 90.00



90.03 AMBULATORY CARE 91,221 6,266,578 0.014557 0 0 90.03

90.04 OTHER 0 0 0.000000 0 0 90.04

91.00 EMERGENCY 1,929,163 182,335,178 0.010580 5,005 53 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 183,319 5,701,212 0.032154 0 0 92.00

200.00 Total (lines 50-199) 25,977,683 1,950,943,131 13,701,915 98,080 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




THROUGH COSTS


IRF

PPS


Anesthetist

Cost


Medical

Education Cost

Total Cost

(sum of col 1

through col.

4)

1.00 2.00 3.00 4.00 5.00


50.00 OPERATING ROOM 0 0 119,373 0 119,373 50.00

51.00 RECOVERY ROOM 0 0 11,208 0 11,208 51.00


53.00 ANESTHESIOLOGY 0 0 6,896 0 6,896 53.00


57.00 CT SCAN 0 0 0 0 0 57.00



60.00 LABORATORY 0 0 53,680 0 53,680 60.00













74.00 RENAL DIALYSIS 0 0 5,094 0 5,094 74.00

76.00 DEV EVALUATION 0 0 3,291 0 3,291 76.00





90.00 CLINIC 0 0 0 0 0 90.00



90.03 AMBULATORY CARE 0 0 6,046 0 6,046 90.03

90.04 OTHER 0 0 0 0 0 90.04

91.00 EMERGENCY 0 0 74,640 0 74,640 91.00


200.00 Total (lines 50-199) 0 0 796,845 0 796,845 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




THROUGH COSTS


IRF

PPS


Outpatient

Cost (sum of

col. 2, 3 and

4)

Total Charges

(from Wkst. C,

Part I, col.

8)

Ratio of Cost

to Charges

(col. 5 ÷ col.

7)

Outpatient

Ratio of Cost

to Charges

(col. 6 ÷ col.

7)

Inpatient

Program

Charges

6.00 7.00 8.00 9.00 10.00


50.00 OPERATING ROOM 119,373 262,277,988 0.000455 0.000455 133,279 50.00

51.00 RECOVERY ROOM 11,208 41,782,683 0.000268 0.000268 34,284 51.00

52.00 DELIVERY ROOM & LABOR ROOM 23,234 36,563,633 0.000635 0.000635 0 52.00

53.00 ANESTHESIOLOGY 6,896 51,326,787 0.000134 0.000134 25,068 53.00

54.00 RADIOLOGY-DIAGNOSTIC 91,625 295,648,937 0.000310 0.000310 718,289 54.00

57.00 CT SCAN 0 0 0.000000 0.000000 0 57.00



60.00 LABORATORY 53,680 197,587,190 0.000272 0.000272 1,228,160 60.00

60.01 BLOOD LABORATORY 8,087 32,253,237 0.000251 0.000251 103,916 60.01


65.00 RESPIRATORY THERAPY 35,326 118,932,516 0.000297 0.000297 619,874 65.00

66.00 PHYSICAL THERAPY 13,033 45,988,420 0.000283 0.000283 6,315 66.00

67.00 OCCUPATIONAL THERAPY 12,970 19,532,239 0.000664 0.000664 6,644,990 67.00


69.00 ELECTROCARDIOLOGY 14,195 52,338,067 0.000271 0.000271 106,609 69.00


71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 137,052 114,499,615 0.001197 0.001197 629,838 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 89,515 164,409,196 0.000544 0.000544 12,246 72.00


74.00 RENAL DIALYSIS 5,094 8,128,811 0.000627 0.000627 287,612 74.00

76.00 DEV EVALUATION 3,291 3,264,573 0.001008 0.001008 1,003 76.00

76.97 CARDIAC REHABILITATION 2,173 3,035,990 0.000716 0.000716 0 76.97




90.00 CLINIC 0 0 0.000000 0.000000 0 90.00



90.03 AMBULATORY CARE 6,046 6,266,578 0.000965 0.000965 0 90.03

90.04 OTHER 0 0 0.000000 0.000000 0 90.04

91.00 EMERGENCY 74,640 182,335,178 0.000409 0.000409 5,005 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 16,879 5,701,212 0.002961 0.002961 0 92.00

200.00 Total (lines 50-199) 796,845 1,950,943,131 13,701,915 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part IV

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




THROUGH COSTS


IRF

PPS


Program

Pass-Through

Costs (col. 8

x col. 10)

Outpatient

Program

Charges

Outpatient

Program

Pass-Through

Costs (col. 9

x col. 12)

11.00 12.00 13.00


50.00 OPERATING ROOM 61 0 0 50.00

51.00 RECOVERY ROOM 9 0 0 51.00




57.00 CT SCAN 0 0 0 57.00



60.00 LABORATORY 334 0 0 60.00





67.00 OCCUPATIONAL THERAPY 4,412 0 0 67.00








74.00 RENAL DIALYSIS 180 0 0 74.00






90.00 CLINIC 0 0 0 90.00




90.04 OTHER 0 0 0 90.04

91.00 EMERGENCY 2 0 0 91.00


200.00 Total (lines 50-199) 6,962 0 0 200.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part V

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Charges

Cost Center Description Cost to Charge

Ratio From

Worksheet C,

Part I, col. 9

PPS Reimbursed

Services (see

instructions)

Cost

Reimbursed

Services

Subject To

Ded. & Coins.

(see

instructions)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see

instructions)

1.00 2.00 3.00 4.00


50.00 OPERATING ROOM 0.252406 0 0 0 50.00

51.00 RECOVERY ROOM 0.156905 0 0 0 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0.371688 0 0 0 52.00

53.00 ANESTHESIOLOGY 0.066863 0 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.181283 0 0 0 54.00

57.00 CT SCAN 0.000000 0 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0.000000 0 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0.000000 0 0 0 59.00

60.00 LABORATORY 0.158918 0 0 0 60.00

60.01 BLOOD LABORATORY 0.146665 0 0 0 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0.000000 0 0 0 62.00

65.00 RESPIRATORY THERAPY 0.173750 0 0 0 65.00

66.00 PHYSICAL THERAPY 0.165765 0 0 0 66.00

67.00 OCCUPATIONAL THERAPY 0.388425 0 0 0 67.00

68.00 SPEECH PATHOLOGY 0.000000 0 0 0 68.00

69.00 ELECTROCARDIOLOGY 0.147958 0 0 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 0.257669 0 0 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.700167 0 0 0 71.00



73.00 DRUGS CHARGED TO PATIENTS 0.136045 0 0 0 73.00

74.00 RENAL DIALYSIS 0.366526 0 0 0 74.00

76.00 DEV EVALUATION 0.589629 0 0 0 76.00

76.97 CARDIAC REHABILITATION 0.418599 0 0 0 76.97




90.00 CLINIC 0.000000 0 0 0 90.00

90.01 FAMILY PRACTICES 0.000000 0 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0.000000 0 0 0 90.02

90.03 AMBULATORY CARE 0.564388 0 0 0 90.03

90.04 OTHER 0.000000 0 0 0 90.04

91.00 EMERGENCY 0.209560 0 0 0 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0.816497 0 0 0 92.00

200.00 Subtotal (see instructions) 0 0 0 200.00


Charges

0 0 201.00

202.00 Net Charges (line 200 +/- line 201) 0 0 0 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D

Part V

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Costs

Cost Center Description PPS Services

(see

instructions)

Cost Services

Subject To

Ded. & Coins.

(see

instructions)

Cost Services

Not Subject To

Ded. & Coins.

(see

instructions)

5.00 6.00 7.00


50.00 OPERATING ROOM 0 0 0 50.00

51.00 RECOVERY ROOM 0 0 0 51.00




57.00 CT SCAN 0 0 0 57.00



60.00 LABORATORY 0 0 0 60.00





67.00 OCCUPATIONAL THERAPY 0 0 0 67.00








74.00 RENAL DIALYSIS 0 0 0 74.00






90.00 CLINIC 0 0 0 90.00




90.04 OTHER 0 0 0 90.04

91.00 EMERGENCY 0 0 0 91.00


200.00 Subtotal (see instructions) 0 0 0 200.00


Charges

0 201.00

202.00 Net Charges (line 200 +/- line 201) 0 0 0 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208COMPUTATION OF INPATIENT OPERATING COST


Cost Center Description

1.00

PART I - ALL PROVIDER COMPONENTS

INPATIENT DAYS

1.00 Inpatient days (including private room days and swing-bed days, excluding newborn) 147,372 1.00

2.00 Inpatient days (including private room days, excluding swing-bed and newborn days) 147,372 2.00

3.00 Private room days (excluding swing-bed and observation bed days) 0 3.00

4.00 Semi-private room days (excluding swing-bed and observation bed days) 147,372 4.00

5.00 Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost

reporting period

0 5.00

6.00 Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost

reporting period (if calendar year, enter 0 on this line)

0 6.00

7.00 Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost

reporting period

0 7.00

8.00 Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost


0 8.00

9.00 Total inpatient days including private room days applicable to the Program (excluding swing-bed and

newborn days)

57,821 9.00

10.00 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days)

through December 31 of the cost reporting period (see instructions)

0 10.00

11.00 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after

December 31 of the cost reporting period (if calendar year, enter 0 on this line)

0 11.00

12.00 Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days)

through December 31 of the cost reporting period

0 12.00


after December 31 of the cost reporting period (if calendar year, enter 0 on this line)

0 13.00

14.00 Medically necessary private room days applicable to the Program (excluding swing-bed days) 0 14.00

15.00 Total nursery days (title V or XIX only) 0 15.00

16.00 Nursery days (title V or XIX only) 0 16.00

SWING BED ADJUSTMENT

17.00 Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost

reporting period

0.00 17.00

18.00 Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost

reporting period

0.00 18.00

19.00 Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost

reporting period

0.00 19.00

20.00 Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost

reporting period

0.00 20.00

21.00 Total general inpatient routine service cost (see instructions) 164,394,514 21.00

22.00 Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line

5 x line 17)

0 22.00

23.00 Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6

x line 18)

0 23.00

24.00 Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line

7 x line 19)

0 24.00

25.00 Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8

x line 20)

0 25.00

26.00 Total swing-bed cost (see instructions) 0 26.00

27.00 General inpatient routine service cost net of swing-bed cost (line 21 minus line 26) 164,394,514 27.00

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT

28.00 General inpatient routine service charges (excluding swing-bed charges) 260,147,636 28.00

29.00 Private room charges (excluding swing-bed charges) 0 29.00

30.00 Semi-private room charges (excluding swing-bed charges) 260,147,636 30.00

31.00 General inpatient routine service cost/charge ratio (line 27 ÷ line 28) 0.631928 31.00

32.00 Average private room per diem charge (line 29 ÷ line 3) 0.00 32.00

33.00 Average semi-private room per diem charge (line 30 ÷ line 4) 1,765.24 33.00

34.00 Average per diem private room charge differential (line 32 minus line 33)(see instructions) 0.00 34.00

35.00 Average per diem private room cost differential (line 34 x line 31) 0.00 35.00

36.00 Private room cost differential adjustment (line 3 x line 35) 0 36.00

37.00 General inpatient routine service cost net of swing-bed cost and private room cost differential (line

27 minus line 36)

164,394,514 37.00

PART II - HOSPITAL AND SUBPROVIDERS ONLY

PROGRAM INPATIENT OPERATING COST BEFORE PASS THROUGH COST ADJUSTMENTS

38.00 Adjusted general inpatient routine service cost per diem (see instructions) 1,115.51 38.00

39.00 Program general inpatient routine service cost (line 9 x line 38) 64,499,904 39.00

40.00 Medically necessary private room cost applicable to the Program (line 14 x line 35) 0 40.00

41.00 Total Program general inpatient routine service cost (line 39 + line 40) 64,499,904 41.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




Inpatient Cost

Total

Inpatient Days

Average Per

Diem (col. 1 ÷

col. 2)

Program Days Program Cost

(col. 3 x col.

4)

1.00 2.00 3.00 4.00 5.00

42.00 NURSERY (title V & XIX only) 0 0 0.00 0 0 42.00

Intensive Care Type Inpatient Hospital Units

43.00 INTENSIVE CARE UNIT 53,102,125 28,759 1,846.45 11,908 21,987,527 43.00

43.01 NEONATAL INTENSIVE CARE UNIT 13,940,652 10,910 1,277.79 0 0 43.01

44.00 CORONARY CARE UNIT 0 0 0.00 0 0 44.00

45.00 BURN INTENSIVE CARE UNIT 0 0 0.00 0 0 45.00

46.00 SURGICAL INTENSIVE CARE UNIT 0 0 0.00 0 0 46.00



1.00

48.00 Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200) 114,418,860 48.00

49.00 Total Program inpatient costs (sum of lines 41 through 48)(see instructions) 200,906,291 49.00

PASS THROUGH COST ADJUSTMENTS

50.00 Pass through costs applicable to Program inpatient routine services (from Wkst. D, sum of Parts I and

III)

3,537,334 50.00

51.00 Pass through costs applicable to Program inpatient ancillary services (from Wkst. D, sum of Parts II

and IV)

6,073,071 51.00

52.00 Total Program excludable cost (sum of lines 50 and 51) 9,610,405 52.00

53.00 Total Program inpatient operating cost excluding capital related, non-physician anesthetist, and

medical education costs (line 49 minus line 52)

191,295,886 53.00

TARGET AMOUNT AND LIMIT COMPUTATION

54.00 Program discharges 0 54.00

55.00 Target amount per discharge 0.00 55.00

56.00 Target amount (line 54 x line 55) 0 56.00

57.00 Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53) 0 57.00

58.00 Bonus payment (see instructions) 0 58.00

59.00 Lesser of lines 53/54 or 55 from the cost reporting period ending 1996, updated and compounded by the

market basket

0.00 59.00

60.00 Lesser of lines 53/54 or 55 from prior year cost report, updated by the market basket 0.00 60.00

61.00 If line 53/54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by

which operating costs (line 53) are less than expected costs (lines 54 x 60), or 1% of the target

amount (line 56), otherwise enter zero (see instructions)

0 61.00

62.00 Relief payment (see instructions) 0 62.00

63.00 Allowable Inpatient cost plus incentive payment (see instructions) 0 63.00

PROGRAM INPATIENT ROUTINE SWING BED COST

64.00 Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (See

instructions)(title XVIII only)

0 64.00

65.00 Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (See


0 65.00

66.00 Total Medicare swing-bed SNF inpatient routine costs (line 64 plus line 65)(title XVIII only). For

CAH (see instructions)

0 66.00

67.00 Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period

(line 12 x line 19)

0 67.00

68.00 Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period

(line 13 x line 20)

0 68.00

69.00 Total title V or XIX swing-bed NF inpatient routine costs (line 67 + line 68) 0 69.00

PART III - SKILLED NURSING FACILITY, OTHER NURSING FACILITY, AND ICF/MR ONLY

70.00 Skilled nursing facility/other nursing facility/ICF/MR routine service cost (line 37) 70.00

71.00 Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2) 71.00

72.00 Program routine service cost (line 9 x line 71) 72.00

73.00 Medically necessary private room cost applicable to Program (line 14 x line 35) 73.00

74.00 Total Program general inpatient routine service costs (line 72 + line 73) 74.00

75.00 Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Part II, column

26, line 45)

75.00

76.00 Per diem capital-related costs (line 75 ÷ line 2) 76.00

77.00 Program capital-related costs (line 9 x line 76) 77.00

78.00 Inpatient routine service cost (line 74 minus line 77) 78.00

79.00 Aggregate charges to beneficiaries for excess costs (from provider records) 79.00

80.00 Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79) 80.00

81.00 Inpatient routine service cost per diem limitation 81.00

82.00 Inpatient routine service cost limitation (line 9 x line 81) 82.00

83.00 Reasonable inpatient routine service costs (see instructions) 83.00

84.00 Program inpatient ancillary services (see instructions) 84.00

85.00 Utilization review - physician compensation (see instructions) 85.00

86.00 Total Program inpatient operating costs (sum of lines 83 through 85) 86.00

PART IV - COMPUTATION OF OBSERVATION BED PASS THROUGH COST

87.00 Total observation bed days (see instructions) 4,173 87.00

88.00 Adjusted general inpatient routine cost per diem (line 27 ÷ line 2) 1,115.51 88.00

89.00 Observation bed cost (line 87 x line 88) (see instructions) 4,655,023 89.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



Cost Center Description Cost Routine Cost

(from line 27)

column 1 ÷

column 2

Total

Observation

Bed Cost (from

line 89)

Observation

Bed Pass

Through Cost

(col. 3 x col.

4) (see

instructions)

1.00 2.00 3.00 4.00 5.00

COMPUTATION OF OBSERVATION BED PASS THROUGH COST

90.00 Capital-related cost 6,473,947 164,394,514 0.039381 4,655,023 183,319 90.00

91.00 Nursing School cost 0 164,394,514 0.000000 4,655,023 0 91.00

92.00 Allied health cost 596,078 164,394,514 0.003626 4,655,023 16,879 92.00

93.00 All other Medical Education 0 164,394,514 0.000000 4,655,023 0 93.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



COMPUTATION OF INPATIENT OPERATING COST


IPF

PPS


1.00


INPATIENT DAYS






reporting period

0 5.00



0 6.00


reporting period

0 7.00



0 8.00


newborn days)

4,494 9.00



0 10.00



0 11.00



0 12.00



0 13.00






reporting period

0.00 17.00


reporting period

0.00 18.00


reporting period

0.00 19.00


reporting period

0.00 20.00



5 x line 17)

0 22.00


x line 18)

0 23.00


7 x line 19)

0 24.00


x line 20)

0 25.00














27 minus line 36)

8,173,572 37.00



38.00 Adjusted general inpatient routine service cost per diem (see instructions) 852.48 38.00





MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IPF

PPS


Inpatient Cost

Total

Inpatient Days

Average Per

Diem (col. 1 ÷

col. 2)


(col. 3 x col.

4)

1.00 2.00 3.00 4.00 5.00



43.00 INTENSIVE CARE UNIT 0 0 0.00 0 0 43.00

43.01 NEONATAL INTENSIVE CARE UNIT 0 0 0.00 0 0 43.01






1.00

48.00 Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200) 705,548 48.00




III)

119,540 50.00


and IV)

32,358 51.00

52.00 Total Program excludable cost (sum of lines 50 and 51) 151,898 52.00



4,384,695 53.00








market basket

0.00 59.00





0 61.00






0 64.00



0 65.00



0 66.00


(line 12 x line 19)

0 67.00


(line 13 x line 20)

0 68.00









26, line 45)

75.00













87.00 Total observation bed days (see instructions) 0 87.00

88.00 Adjusted general inpatient routine cost per diem (line 27 ÷ line 2) 0.00 88.00

89.00 Observation bed cost (line 87 x line 88) (see instructions) 0 89.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IPF

PPS


(from line 27)

column 1 ÷

column 2

Total

Observation

Bed Cost (from

line 89)

Observation

Bed Pass

Through Cost

(col. 3 x col.

4) (see

instructions)

1.00 2.00 3.00 4.00 5.00


90.00 Capital-related cost 221,940 8,173,572 0.027153 0 0 90.00

91.00 Nursing School cost 0 8,173,572 0.000000 0 0 91.00

92.00 Allied health cost 33,067 8,173,572 0.004046 0 0 92.00

93.00 All other Medical Education 0 8,173,572 0.000000 0 0 93.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IRF

PPS


1.00


INPATIENT DAYS






reporting period

0 5.00



0 6.00


reporting period

0 7.00



0 8.00


newborn days)

7,087 9.00



0 10.00



0 11.00



0 12.00



0 13.00






reporting period

0.00 17.00


reporting period

0.00 18.00


reporting period

0.00 19.00


reporting period

0.00 20.00



5 x line 17)

0 22.00


x line 18)

0 23.00


7 x line 19)

0 24.00


x line 20)

0 25.00














27 minus line 36)

10,446,182 37.00



38.00 Adjusted general inpatient routine service cost per diem (see instructions) 833.29 38.00





MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IRF

PPS


Inpatient Cost

Total

Inpatient Days

Average Per

Diem (col. 1 ÷

col. 2)


(col. 3 x col.

4)

1.00 2.00 3.00 4.00 5.00



43.00 INTENSIVE CARE UNIT 0 0 0.00 0 0 43.00

43.01 NEONATAL INTENSIVE CARE UNIT 0 0 0.00 0 0 43.01






1.00

48.00 Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200) 4,067,776 48.00




III)

173,845 50.00


and IV)

105,042 51.00

52.00 Total Program excludable cost (sum of lines 50 and 51) 278,887 52.00



9,694,415 53.00








market basket

0.00 59.00





0 61.00






0 64.00



0 65.00



0 66.00


(line 12 x line 19)

0 67.00


(line 13 x line 20)

0 68.00









26, line 45)

75.00













87.00 Total observation bed days (see instructions) 0 87.00

88.00 Adjusted general inpatient routine cost per diem (line 27 ÷ line 2) 0.00 88.00

89.00 Observation bed cost (line 87 x line 88) (see instructions) 0 89.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IRF

PPS


(from line 27)

column 1 ÷

column 2

Total

Observation

Bed Cost (from

line 89)

Observation

Bed Pass

Through Cost

(col. 3 x col.

4) (see

instructions)

1.00 2.00 3.00 4.00 5.00


90.00 Capital-related cost 264,639 10,446,182 0.025334 0 0 90.00

91.00 Nursing School cost 0 10,446,182 0.000000 0 0 91.00

92.00 Allied health cost 42,823 10,446,182 0.004099 0 0 92.00

93.00 All other Medical Education 0 10,446,182 0.000000 0 0 93.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-3

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208INPATIENT ANCILLARY SERVICE COST APPORTIONMENT


Cost Center Description Ratio of Cost

To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x col.

2)

1.00 2.00 3.00


30.00 ADULTS & PEDIATRICS 101,694,368 30.00

31.00 INTENSIVE CARE UNIT 47,366,645 31.00

31.01 NEONATAL INTENSIVE CARE UNIT 0 31.01







43.00 NURSERY 43.00


50.00 OPERATING ROOM 0.252406 57,985,135 14,635,796 50.00

51.00 RECOVERY ROOM 0.156905 8,516,262 1,336,244 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0.371688 152,275 56,599 52.00

53.00 ANESTHESIOLOGY 0.066863 10,064,192 672,922 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.181283 67,755,904 12,282,994 54.00

57.00 CT SCAN 0.000000 0 0 57.00

58.00 MAGNETIC RESONANCE IMAGING (MRI) 0.000000 0 0 58.00

59.00 CARDIAC CATHETERIZATION 0.000000 0 0 59.00

60.00 LABORATORY 0.158918 56,925,131 9,046,428 60.00

60.01 BLOOD LABORATORY 0.146665 10,393,283 1,524,331 60.01

62.00 WHOLE BLOOD & PACKED RED BLOOD CELLS 0.000000 0 0 62.00

65.00 RESPIRATORY THERAPY 0.173750 35,567,702 6,179,888 65.00

66.00 PHYSICAL THERAPY 0.165765 6,981,551 1,157,297 66.00

67.00 OCCUPATIONAL THERAPY 0.388425 153,708 59,704 67.00

68.00 SPEECH PATHOLOGY 0.000000 0 0 68.00

69.00 ELECTROCARDIOLOGY 0.147958 14,101,334 2,086,405 69.00

70.00 ELECTROENCEPHALOGRAPHY 0.257669 633,860 163,326 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.700167 37,432,492 26,208,996 71.00

71.30 IMPL. DEV. CHARGED TO PATIENT 0.000000 0 0 71.30

72.00 IMPL. DEV. CHARGED TO PATIENT 0.318483 56,452,999 17,979,320 72.00

73.00 DRUGS CHARGED TO PATIENTS 0.136045 91,486,330 12,446,258 73.00

74.00 RENAL DIALYSIS 0.366526 5,008,738 1,835,833 74.00

76.00 DEV EVALUATION 0.589629 4,300 2,535 76.00

76.97 CARDIAC REHABILITATION 0.418599 590,303 247,100 76.97


88.00 RURAL HEALTH CLINIC 0.000000 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0.000000 0 89.00

90.00 CLINIC 0.000000 0 0 90.00

90.01 FAMILY PRACTICES 0.000000 0 0 90.01

90.02 WOMEN'S HEALTH CENTER 0.000000 0 0 90.02

90.03 AMBULATORY CARE 0.564388 70,806 39,962 90.03

90.04 OTHER 0.000000 0 0 90.04

91.00 EMERGENCY 0.209560 28,154,660 5,900,091 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0.816497 681,975 556,831 92.00

200.00 Total (sum of lines 50-94 and 96-98) 489,112,940 114,418,860 200.00

201.00 Less PBP Clinic Laboratory Services-Program only charges (line 61) 0 201.00

202.00 Net Charges (line 200 minus line 201) 489,112,940 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-3

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



INPATIENT ANCILLARY SERVICE COST APPORTIONMENT


IPF

PPS


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x col.

2)

1.00 2.00 3.00


30.00 ADULTS & PEDIATRICS 0 30.00

31.00 INTENSIVE CARE UNIT 0 31.00





40.00 SUBPROVIDER - IPF 6,819,968 40.00



43.00 NURSERY 43.00


50.00 OPERATING ROOM 0.252406 1,804 455 50.00

51.00 RECOVERY ROOM 0.156905 751 118 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0.371688 1,319 490 52.00

53.00 ANESTHESIOLOGY 0.066863 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.181283 307,648 55,771 54.00

57.00 CT SCAN 0.000000 0 0 57.00



60.00 LABORATORY 0.158918 798,842 126,950 60.00

60.01 BLOOD LABORATORY 0.146665 1,092 160 60.01


65.00 RESPIRATORY THERAPY 0.173750 244,967 42,563 65.00

66.00 PHYSICAL THERAPY 0.165765 87,318 14,474 66.00

67.00 OCCUPATIONAL THERAPY 0.388425 132,770 51,571 67.00


69.00 ELECTROCARDIOLOGY 0.147958 191,791 28,377 69.00


71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.700167 45,209 31,654 71.00



73.00 DRUGS CHARGED TO PATIENTS 0.136045 1,506,621 204,968 73.00

74.00 RENAL DIALYSIS 0.366526 59,662 21,868 74.00

76.00 DEV EVALUATION 0.589629 58 34 76.00

76.97 CARDIAC REHABILITATION 0.418599 0 0 76.97




90.00 CLINIC 0.000000 0 0 90.00



90.03 AMBULATORY CARE 0.564388 220 124 90.03

90.04 OTHER 0.000000 0 0 90.04

91.00 EMERGENCY 0.209560 593,097 124,289 91.00

92.00 OBSERVATION BEDS (NON-DISTINCT PART) 0.816497 0 0 92.00

200.00 Total (sum of lines 50-94 and 96-98) 3,979,698 705,548 200.00




MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-3

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IRF

PPS


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x col.

2)

1.00 2.00 3.00









41.00 SUBPROVIDER - IRF 8,886,880 41.00


43.00 NURSERY 43.00


50.00 OPERATING ROOM 0.252406 133,279 33,640 50.00

51.00 RECOVERY ROOM 0.156905 34,284 5,379 51.00

52.00 DELIVERY ROOM & LABOR ROOM 0.371688 0 0 52.00

53.00 ANESTHESIOLOGY 0.066863 25,068 1,676 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.181283 718,289 130,214 54.00

57.00 CT SCAN 0.000000 0 0 57.00



60.00 LABORATORY 0.158918 1,228,160 195,177 60.00

60.01 BLOOD LABORATORY 0.146665 103,916 15,241 60.01


65.00 RESPIRATORY THERAPY 0.173750 619,874 107,703 65.00

66.00 PHYSICAL THERAPY 0.165765 6,315 1,047 66.00

67.00 OCCUPATIONAL THERAPY 0.388425 6,644,990 2,581,080 67.00


69.00 ELECTROCARDIOLOGY 0.147958 106,609 15,774 69.00


71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.700167 629,838 440,992 71.00


72.00 IMPL. DEV. CHARGED TO PATIENT 0.318483 12,246 3,900 72.00

73.00 DRUGS CHARGED TO PATIENTS 0.136045 3,137,401 426,828 73.00

74.00 RENAL DIALYSIS 0.366526 287,612 105,417 74.00

76.00 DEV EVALUATION 0.589629 1,003 591 76.00





90.00 CLINIC 0.000000 0 0 90.00



90.03 AMBULATORY CARE 0.564388 0 0 90.03

90.04 OTHER 0.000000 0 0 90.04

91.00 EMERGENCY 0.209560 5,005 1,049 91.00


200.00 Total (sum of lines 50-94 and 96-98) 13,701,915 4,067,776 200.00




MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-3

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208INPATIENT ANCILLARY SERVICE COST APPORTIONMENT



To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x col.

2)

1.00 2.00 3.00











43.00 NURSERY 0 43.00


50.00 OPERATING ROOM 0.252406 0 0 50.00

51.00 RECOVERY ROOM 0.156905 0 0 51.00


53.00 ANESTHESIOLOGY 0.066863 0 0 53.00

54.00 RADIOLOGY-DIAGNOSTIC 0.181283 0 0 54.00

57.00 CT SCAN 0.000000 0 0 57.00



60.00 LABORATORY 0.158918 0 0 60.00

60.01 BLOOD LABORATORY 0.146665 0 0 60.01


65.00 RESPIRATORY THERAPY 0.173750 0 0 65.00

66.00 PHYSICAL THERAPY 0.165765 0 0 66.00

67.00 OCCUPATIONAL THERAPY 0.388425 0 0 67.00


69.00 ELECTROCARDIOLOGY 0.147958 0 0 69.00

70.00 ELECTROENCEPHALOGRAPHY 0.257669 0 0 70.00

71.00 MEDICAL SUPPLIES CHARGED TO PATIENTS 0.700167 0 0 71.00



73.00 DRUGS CHARGED TO PATIENTS 0.136045 0 0 73.00

74.00 RENAL DIALYSIS 0.366526 0 0 74.00

76.00 DEV EVALUATION 0.589629 0 0 76.00



88.00 RURAL HEALTH CLINIC 0.000000 0 0 88.00

89.00 FEDERALLY QUALIFIED HEALTH CENTER 0.000000 0 0 89.00

90.00 CLINIC 0.000000 0 0 90.00



90.03 AMBULATORY CARE 0.564388 0 0 90.03

90.04 OTHER 0.000000 0 0 90.04

91.00 EMERGENCY 0.209560 0 0 91.00


200.00 Total (sum of lines 50-94 and 96-98) 0 0 200.00


202.00 Net Charges (line 200 minus line 201) 0 202.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-3

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




Title XIX Subprovider -

IPF

Cost


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x col.

2)

1.00 2.00 3.00











43.00 NURSERY 0 43.00


50.00 OPERATING ROOM 0.252406 0 0 50.00

51.00 RECOVERY ROOM 0.156905 0 0 51.00


53.00 ANESTHESIOLOGY 0.066863 0 0 53.00


57.00 CT SCAN 0.000000 0 0 57.00



60.00 LABORATORY 0.158918 0 0 60.00













74.00 RENAL DIALYSIS 0.366526 0 0 74.00

76.00 DEV EVALUATION 0.589629 0 0 76.00





90.00 CLINIC 0.000000 0 0 90.00



90.03 AMBULATORY CARE 0.564388 0 0 90.03

90.04 OTHER 0.000000 0 0 90.04

91.00 EMERGENCY 0.209560 0 0 91.00






MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet D-3

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011




Title XIX Subprovider -

IRF

Cost


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x col.

2)

1.00 2.00 3.00











43.00 NURSERY 0 43.00


50.00 OPERATING ROOM 0.252406 0 0 50.00

51.00 RECOVERY ROOM 0.156905 0 0 51.00


53.00 ANESTHESIOLOGY 0.066863 0 0 53.00


57.00 CT SCAN 0.000000 0 0 57.00



60.00 LABORATORY 0.158918 0 0 60.00













74.00 RENAL DIALYSIS 0.366526 0 0 74.00

76.00 DEV EVALUATION 0.589629 0 0 76.00





90.00 CLINIC 0.000000 0 0 90.00



90.03 AMBULATORY CARE 0.564388 0 0 90.03

90.04 OTHER 0.000000 0 0 90.04

91.00 EMERGENCY 0.209560 74 16 91.00






MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E

Part A

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208CALCULATION OF REIMBURSEMENT SETTLEMENT


1.00

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS

1.00 DRG Amounts Other than Outlier Payments 129,794,022 1.00

2.00 Outlier payments for discharges. (see instructions) 7,080,506 2.00

3.00 Managed Care Simulated Payments 22,794,731 3.00

4.00 Bed days available divided by number of days in the cost reporting period (see instructions) 579.57 4.00

Indirect Medical Education Adjustment

5.00 FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on

or before 12/31/1996.(see instructions)

171.79 5.00

6.00 FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap

for new programs in accordance with 42 CFR 413.79(e)

44.81 6.00

7.00 MMA Section 422 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(1) 0.00 7.00

7.01 ACA Section 5503 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(2)

If the cost report straddles July 1, 2011 then see instructions.

0.00 7.01

8.00 Adjustment (increase or decrease) to the FTE count for allopathic and osteopathic programs for

affiliated programs in accordance with 42 CFR 413.75(b), 413.79(c)(2)(iv) and Vol. 64 Federal

Register, May 12, 1998, page 26340 and Vol. 67 Federal Register, page 50069, August 1, 2002.

0.00 8.00

8.01 The amount of increase if the hospital was awarded FTE cap slots under section 5503 of the ACA. If

the cost report straddles July 1, 2011, see instructions.

0.00 8.01

8.02 The amount of increase if the hospital was awarded FTE cap slots from a closed teaching hospital

under section 5506 of ACA. (see instructions)

0.00 8.02

9.00 Sum of lines 5 plus 6 minus lines (7 and 7.01) plus/minus lines (8, 8,01 and 8,02) (see

instructions)

216.60 9.00

10.00 FTE count for allopathic and osteopathic programs in the current year from your records 214.23 10.00

11.00 FTE count for residents in dental and podiatric programs. 0.00 11.00

12.00 Current year allowable FTE (see instructions) 214.23 12.00

13.00 Total allowable FTE count for the prior year. 216.59 13.00

14.00 Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997,

otherwise enter zero.

210.93 14.00

15.00 Sum of lines 12 through 14 divided by 3. 213.92 15.00

16.00 Adjustment for residents in initial years of the program 0.00 16.00

17.00 Adjusment for residents displaced by program or hospital closure 0.00 17.00

18.00 Adjusted rolling average FTE count 213.92 18.00

19.00 Current year resident to bed ratio (line 18 divided by line 4). 0.369101 19.00

20.00 Prior year resident to bed ratio (see instructions) 0.373709 20.00

21.00 Enter the lesser of lines 19 or 20 (see instructions) 0.369101 21.00

22.00 IME payment adjustment (see instructions) 27,949,529 22.00

Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA

23.00 Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105

(f)(1)(iv)(C ).

0.00 23.00

24.00 IME FTE Resident Count Over Cap (see instructions) 0.00 24.00

25.00 If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see

instructions)

0.00 25.00

26.00 Resident to bed ratio (divide line 25 by line 4) 0.000000 26.00

27.00 IME payments adjustment. (see instructions) 0.000000 27.00

28.00 IME Adjustment (see instructions) 0 28.00

29.00 Total IME payment ( sum of lines 22 and 28) 27,949,529 29.00

Disproportionate Share Adjustment

30.00 Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions) 3.81 30.00

31.00 Percentage of Medicaid patient days to total days reported on Worksheet S-2, Part I, line 24. (see

instructions)

27.22 31.00

32.00 Sum of lines 30 and 31 31.03 32.00

33.00 Allowable disproportionate share percentage (see instructions) 14.81 33.00

34.00 Disproportionate share adjustment (see instructions) 19,222,495 34.00

Additional payment for high percentage of ESRD beneficiary discharges

40.00 Total Medicare discharges on Worksheet S-3, Part I excluding discharges for MS-DRGs 652, 682, 683,

684 and 685 (see instructions)

0 40.00

41.00 Total ESRD Medicare discharges excluding MS-DRGs 652, 682, 683, 684 an 685. (see instructions) 0 41.00

42.00 Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment) 0.00 42.00

43.00 Total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684 an 685. (see instructions) 0 43.00

44.00 Ratio of average length of stay to one week (line 43 divided by line 41 divided by 7 days) 0.000000 44.00

45.00 Average weekly cost for dialysis treatments (see instructions) 0.00 45.00

46.00 Total additional payment (line 45 times line 44 times line 41) 0 46.00

47.00 Subtotal (see instructions) 184,046,552 47.00

48.00 Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only.(see

instructions)

0 48.00

49.00 Total payment for inpatient operating costs SCH and MDH only (see instructions) 184,046,552 49.00

50.00 Payment for inpatient program capital (from Worksheet L, Parts I, II, as applicable) 12,740,211 50.00

51.00 Exception payment for inpatient program capital (Worksheet L, Part III, see instructions) 0 51.00

52.00 Direct graduate medical education payment (from Worksheet E-4, line 49 see instructions). 10,663,095 52.00

53.00 Nursing and Allied Health Managed Care payment 98,449 53.00

54.00 Special add-on payments for new technologies 0 54.00

55.00 Net organ acquisition cost (Worksheet D-4 Part III, col. 1, line 69) 0 55.00

56.00 Cost of teaching physicians (Worksheet D-5, Part II, col. 3, line 20) 0 56.00

57.00 Routine service other pass through costs 297,424 57.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E

Part A

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



1.00

58.00 Ancillary service other pass through costs Worksheet D, Part IV, col. 11 line 200) 199,952 58.00

59.00 Total (sum of amounts on lines 49 through 58) 208,045,683 59.00

60.00 Primary payer payments 112,956 60.00

61.00 Total amount payable for program beneficiaries (line 59 minus line 60) 207,932,727 61.00

62.00 Deductibles billed to program beneficiaries 9,311,836 62.00

63.00 Coinsurance billed to program beneficiaries 983,677 63.00

64.00 Allowable bad debts (see instructions) 3,455,184 64.00

65.00 Adjusted reimbursable bad debts (see instructions) 2,418,629 65.00

66.00 Allowable bad debts for dual eligible beneficiaries (see instructions) 1,956,469 66.00

67.00 Subtotal (line 61 plus line 65 minus lines 62 and 63) 200,055,843 67.00

68.00 Credits received from manufacturers for replaced devices applicable to MS-DRG (see instructions) 0 68.00

69.00 Outlier payments reconciliation 0 69.00

70.00 OTHER ADJUSTMENTS (SEE INSTRUCTIONS) (SPECIFY) 0 70.00

70.95 Recovery of Accelerated Depreciation 0 70.95

70.96 Low Volume Payment-1 0 70.96



71.00 Amount due provider (line 67 minus lines 68 plus/minus lines 69 & 70) 200,055,843 71.00

72.00 Interim payments 195,023,592 72.00

73.00 Tentative settlement (for contractor use only) 0 73.00

74.00 Balance due provider (Program) (line 71 minus the sum of lines 72 and 73) 5,032,251 74.00

75.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2 0 75.00

TO BE COMPLETED BY CONTRACTOR

90.00 Operating outlier amount from Worksheet E, Part A line 2 0 90.00

91.00 Capital outlier from Worksheet L, Part I, line 2 0 91.00

92.00 Operating outlier reconciliation adjustment amount (see instructions) 0 92.00

93.00 Capital outlier reconciliation adjustment amount (see instructions) 0 93.00

94.00 The rate used to calculate the Time Value of Money 0.00 94.00

95.00 Time Value of Money for operating expenses(see instructions) 0 95.00

96.00 Time Value of Money for capital related expenses (see instructions) 0 96.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E

Part B

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



1.00

PART B - MEDICAL AND OTHER HEALTH SERVICES

1.00 Medical and other services (see instructions) 0 1.00

2.00 Medical and other services reimbursed under OPPS (see instructions) 31,376,501 2.00

3.00 PPS payments 30,081,166 3.00

4.00 Outlier payment (see instructions) 195,436 4.00

5.00 Enter the hospital specific payment to cost ratio (see instructions) 0.897 5.00

6.00 Line 2 times line 5 28,144,721 6.00

7.00 Sum of line 3 plus line 4 divided by line 6 0.00 7.00

8.00 Transitional corridor payment (see instructions) 0 8.00

9.00 Ancillary service other pass through costs from Worksheet D, Part IV, column 13, line 200 59,530 9.00

10.00 Organ acquisitions 0 10.00

11.00 Total cost (sum of lines 1 and 10) (see instructions) 0 11.00

COMPUTATION OF LESSER OF COST OR CHARGES

Reasonable charges

12.00 Ancillary service charges 0 12.00

13.00 Organ acquisition charges (from Worksheet D-4, Part III, line 69, col. 4) 0 13.00

14.00 Total reasonable charges (sum of lines 12 and 13) 0 14.00

Customary charges

15.00 Aggregate amount actually collected from patients liable for payment for services on a charge basis 0 15.00

16.00 Amounts that would have been realized from patients liable for payment for services on a chargebasis

had such payment been made in accordance with 42 CFR 413.13(e)

0 16.00

17.00 Ratio of line 15 to line 16 (not to exceed 1.000000) 0.000000 17.00

18.00 Total customary charges (see instructions) 0 18.00

19.00 Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see

instructions)

0 19.00

20.00 Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see

instructions)

0 20.00

21.00 Lesser of cost or charges (line 11 minus line 20) (for CAH see instructions) 0 21.00

22.00 Interns and residents (see instructions) 0 22.00

23.00 Cost of teaching physicians (see instructions, 42 CFR 415.160 and CMS Pub. 15-1, section 2148) 0 23.00

24.00 Total prospective payment (sum of lines 3, 4, 8 and 9) 30,336,132 24.00

COMPUTATION OF REIMBURSEMENT SETTLEMENT

25.00 Deductibles and coinsurance (for CAH, see instructions) 6,369,879 25.00

26.00 Deductibles and Coinsurance relating to amount on line 24 (for CAH, see instructions) 0 26.00

27.00 Subtotal {(lines 21 and 24 - the sum of lines 25 and 26) plus the sum of lines 22 and 23} (for CAH,

see instructions)

23,966,253 27.00

28.00 Direct graduate medical education payments (from Worksheet E-4, line 50) 1,556,705 28.00

29.00 ESRD direct medical education costs (from Worksheet E-4, line 36) 0 29.00

30.00 Subtotal (sum of lines 27 through 29) 25,522,958 30.00

31.00 Primary payer payments 4,037 31.00

32.00 Subtotal (line 30 minus line 31) 25,518,921 32.00

ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)

33.00 Composite rate ESRD (from Worksheet I-5, line 11) 0 33.00

34.00 Allowable bad debts (see instructions) 1,867,348 34.00

35.00 Adjusted reimbursable bad debts (see instructions) 1,307,144 35.00

36.00 Allowable bad debts for dual eligible beneficiaries (see instructions) 1,238,136 36.00

37.00 Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only) 26,826,065 37.00

38.00 MSP-LCC reconciliation amount from PS&R 0 38.00


39.99 RECOVERY OF ACCELERATED DEPRECIATION 0 39.99

40.00 Subtotal (line 37 plus or minus lines 39 minus 38) 26,826,065 40.00


42.00 Tentative settlement (for contractors use only) 0 42.00

43.00 Balance due provider/program (line 40 minus the sum of lines 41, and 42) 1,405,271 43.00



90.00 Original outlier amount (see instructions) 0 90.00

91.00 Outlier reconciliation adjustment amount (see instructions) 0 91.00


93.00 Time Value of Money (see instructions) 0 93.00

94.00 Total (sum of lines 91 and 93) 0 94.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E

Part B

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



CALCULATION OF REIMBURSEMENT SETTLEMENT


IPF

PPS

1.00



2.00 Medical and other services reimbursed under OPPS (see instructions) 0 2.00

3.00 PPS payments 0 3.00

4.00 Outlier payment (see instructions) 0 4.00


6.00 Line 2 times line 5 0 6.00



9.00 Ancillary service other pass through costs from Worksheet D, Part IV, column 13, line 200 0 9.00




Reasonable charges




Customary charges




0 16.00




instructions)

0 19.00


instructions)

0 20.00




24.00 Total prospective payment (sum of lines 3, 4, 8 and 9) 0 24.00


25.00 Deductibles and coinsurance (for CAH, see instructions) 0 25.00



see instructions)

0 27.00

28.00 Direct graduate medical education payments (from Worksheet E-4, line 50) 0 28.00


30.00 Subtotal (sum of lines 27 through 29) 0 30.00

31.00 Primary payer payments 0 31.00

32.00 Subtotal (line 30 minus line 31) 0 32.00



34.00 Allowable bad debts (see instructions) 0 34.00

35.00 Adjusted reimbursable bad debts (see instructions) 0 35.00

36.00 Allowable bad debts for dual eligible beneficiaries (see instructions) 0 36.00

37.00 Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only) 0 37.00




40.00 Subtotal (line 37 plus or minus lines 39 minus 38) 0 40.00

41.00 Interim payments 0 41.00


43.00 Balance due provider/program (line 40 minus the sum of lines 41, and 42) 0 43.00









MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E

Part B

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IRF

PPS

1.00



2.00 Medical and other services reimbursed under OPPS (see instructions) 0 2.00

3.00 PPS payments 0 3.00

4.00 Outlier payment (see instructions) 0 4.00


6.00 Line 2 times line 5 0 6.00



9.00 Ancillary service other pass through costs from Worksheet D, Part IV, column 13, line 200 0 9.00




Reasonable charges




Customary charges




0 16.00




instructions)

0 19.00


instructions)

0 20.00




24.00 Total prospective payment (sum of lines 3, 4, 8 and 9) 0 24.00


25.00 Deductibles and coinsurance (for CAH, see instructions) 0 25.00



see instructions)

0 27.00



30.00 Subtotal (sum of lines 27 through 29) 0 30.00


32.00 Subtotal (line 30 minus line 31) 0 32.00



34.00 Allowable bad debts (see instructions) 0 34.00



37.00 Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only) 0 37.00




40.00 Subtotal (line 37 plus or minus lines 39 minus 38) 0 40.00

41.00 Interim payments 0 41.00


43.00 Balance due provider/program (line 40 minus the sum of lines 41, and 42) 0 43.00









MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-1

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED


Inpatient Part A Part B

mm/dd/yyyy Amount mm/dd/yyyy Amount

1.00 2.00 3.00 4.00

1.00 Total interim payments paid to provider 1.00193,464,541 25,348,515

2.00 Interim payments payable on individual bills, either

submitted or to be submitted to the contractor for

services rendered in the cost reporting period. If none,

write "NONE" or enter a zero

2.000 0

3.00 List separately each retroactive lump sum adjustment

amount based on subsequent revision of the interim rate

for the cost reporting period. Also show date of each

payment. If none, write "NONE" or enter a zero. (1)

3.00

Program to Provider

3.01 ADJUSTMENTS TO PROVIDER 3.0108/05/2011 906,843 57,145

3.02 3.0212/16/2011 652,208 12/16/2011 15,134

3.03 3.030 0

3.04 3.040 0

3.05 3.050 0

Provider to Program

3.50 ADJUSTMENTS TO PROGRAM 3.500 0

3.51 3.510 0

3.52 3.520 0

3.53 3.530 0

3.54 3.540 0

3.99 Subtotal (sum of lines 3.01-3.49 minus sum of lines

3.50-3.98)

3.991,559,051 72,279

4.00 Total interim payments (sum of lines 1, 2, and 3.99)

(transfer to Wkst. E or Wkst. E-3, line and column as

appropriate)

4.00195,023,592 25,420,794


5.00 List separately each tentative settlement payment after

desk review. Also show date of each payment. If none,

write "NONE" or enter a zero. (1)

5.00

Program to Provider

5.01 TENTATIVE TO PROVIDER 5.010 0

5.02 5.020 0

5.03 5.030 0

Provider to Program

5.50 TENTATIVE TO PROGRAM 5.500 0

5.51 5.510 0

5.52 5.520 0


5.50-5.98)

5.990 0

6.00 Determined net settlement amount (balance due) based on

the cost report. (1)

6.00

6.01 SETTLEMENT TO PROVIDER 6.015,032,251 1,405,271

6.02 SETTLEMENT TO PROGRAM 6.020 0

7.00 Total Medicare program liability (see instructions) 7.00200,055,843 26,826,065

Contractor

Number

Date

(Mo/Day/Yr)

0 1.00 2.00

8.00 Name of Contractor 8.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-1

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED


IPF

PPS



1.00 2.00 3.00 4.00

1.00 Total interim payments paid to provider 1.003,649,591 0





2.000 0





3.00

Program to Provider

3.01 ADJUSTMENTS TO PROVIDER 3.010 0

3.02 3.020 0

3.03 3.030 0

3.04 3.040 0

3.05 3.050 0

Provider to Program

3.50 ADJUSTMENTS TO PROGRAM 3.5008/05/2011 19,666 0

3.51 3.510 0

3.52 3.520 0

3.53 3.530 0

3.54 3.540 0


3.50-3.98)

3.99-19,666 0



appropriate)

4.003,629,925 0





5.00

Program to Provider


5.02 5.020 0

5.03 5.030 0

Provider to Program


5.51 5.510 0

5.52 5.520 0


5.50-5.98)

5.990 0



6.00

6.01 SETTLEMENT TO PROVIDER 6.013,620 0


7.00 Total Medicare program liability (see instructions) 7.003,633,545 0

Contractor

Number

Date

(Mo/Day/Yr)

0 1.00 2.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-1

Part I

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011



ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED


IRF

PPS



1.00 2.00 3.00 4.00

1.00 Total interim payments paid to provider 1.009,748,865 0





2.000 0





3.00

Program to Provider

3.01 ADJUSTMENTS TO PROVIDER 3.0108/05/2011 36,239 0

3.02 3.020 0

3.03 3.030 0

3.04 3.040 0

3.05 3.050 0

Provider to Program

3.50 ADJUSTMENTS TO PROGRAM 3.500 0

3.51 3.510 0

3.52 3.520 0

3.53 3.530 0

3.54 3.540 0


3.50-3.98)

3.9936,239 0



appropriate)

4.009,785,104 0





5.00

Program to Provider


5.02 5.020 0

5.03 5.030 0

Provider to Program


5.51 5.510 0

5.52 5.520 0


5.50-5.98)

5.990 0



6.00

6.01 SETTLEMENT TO PROVIDER 6.0117,647 0


7.00 Total Medicare program liability (see instructions) 7.009,802,751 0

Contractor

Number

Date

(Mo/Day/Yr)

0 1.00 2.00



MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-1

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208CALCULATION OF REIMBURSEMENT SETTLEMENT FOR HIT


1.00

DATA COLLECTION NEEDED FOR THE HIT CALCULATION

1.00 Total hospital discharges as defined in AARA §4102 from Wkst S-3, Part I column 15 line 14 38,403 1.00

2.00 Medicare days from Wkst S-3, Part I, column 6 sum of lines 1, 8-12 69,729 2.00

3.00 Medicare HMO days from Wkst S-3, Part I, column 6. line 2 10,618 3.00

4.00 Total inpatient days from S-3, Part I column 8 sum of lines 1, 8-12 182,868 4.00

5.00 Total hospital charges from Wkst C, Part I, column 8 line 200 2,406,381,258 5.00

6.00 Total hospital charity care charges from Wkst S-10, column 3 line 20 50,765,911 6.00

7.00 CAH only - The reasonable cost incurred for the purchase of certified HIT technology Worksheet S-2,

Part I line 168

0 7.00

8.00 Calculation of the HIT incentive payment (see instructions) 2,859,207 8.00

INPATIENT HOSPITAL SERVICES UNDER PPS & CAH

30.00 Initial/interim HIT payment(s) 0 30.00

31.00 Other Adjustment (specify) 0 31.00

32.00 Balance due provider (line 8 minus line 30, plus or minus line 31) 2,859,207 32.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-3

Part II

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IPF

PPS

1.00

PART II - MEDICARE PART A SERVICES - IPF PPS

1.00 Net Federal IPF PPS Payments (excluding outlier, ECT, and medical education payments) 3,744,265 1.00

2.00 Net IPF PPS Outlier Payments 138,197 2.00

3.00 Net IPF PPS ECT Payments 62,961 3.00

4.00 Unweighted intern and resident FTE count in the most recent cost report filed on or before November

15, 2004. (see instructions)

0.00 4.00

5.00 New Teaching program adjustment. (see instructions) 0.00 5.00

6.00 Current year's unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching

program". (see inst.)

0.00 6.00

7.00 Current year's unweighted I&R FTE count for residents within the first 3 years of a "new teaching


0.00 7.00

8.00 Intern and resident count for IPF PPS medical education adjustment (see instructions) 0.00 8.00

9.00 Average Daily Census (see instructions) 26.268493 9.00

10.00 Medical Education Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}. 0.000000 10.00

11.00 Medical Education Adjustment (line 1 multiplied by line 10). 0 11.00

12.00 Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3 and 11) 3,945,423 12.00

13.00 Nursing and Allied Health Managed Care payment (see instruction) 0 13.00

14.00 Organ acquisition 0 14.00

15.00 Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 20) (see instructions) 0 15.00



18.00 Subtotal (line 16 less line 17). 3,945,423 18.00

19.00 Deductibles 275,984 19.00


21.00 Coinsurance 52,638 21.00


23.00 Allowable bad debts (exclude bad debts for professional services) (see instructions) 0 23.00



26.00 Subtotal (sum of lines 22 and 24) 3,616,801 26.00


28.00 Other pass through costs (see instructions) 16,744 28.00




31.00 Total amount payable to the provider (see instructions) 3,633,545 31.00



34.00 Balance due provider/program (line 31 minus the sum lines 32 and 33) 3,620 34.00

35.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 0 35.00


50.00 Original outlier amount from Worksheet E-3, Part II, line 2 0 50.00





MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-3

Part III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011





IRF

PPS

1.00

PART III - MEDICARE PART A SERVICES - IRF PPS

1.00 Net Federal PPS Payment (see instructions) 9,335,456 1.00

2.00 Medicare SSI ratio (IRF PPS only) (see instructions) 0.0249 2.00

3.00 Inpatient Rehabilitation LIP Payments (see instructions) 331,530 3.00

4.00 Outlier Payments 216,916 4.00

5.00 Unweighted intern and resident FTE count in the most recent cost reporting period ending on or prior

to November 15, 2004 (see instructions)

0.00 5.00

6.00 New Teaching program adjustment. (see instructions) 0.00 6.00

7.00 Current year's unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching


0.00 7.00

8.00 Current year's unweighted I&R FTE count for residents within the first 3 years of a "new teaching


0.00 8.00

9.00 Intern and resident count for IRF PPS medical education adjustment (see instructions) 0.00 9.00

10.00 Average Daily Census (see instructions) 34.345205 10.00

11.00 Medical Education Adjustment Factor {((1 + (line 9/line 10)) raised to the power of .6876 -1}. 0.000000 11.00

12.00 Medical Education Adjustment (line 1 multiplied by line 11). 0 12.00

13.00 Total PPS Payment (sum of lines 1, 3, 4 and 12) 9,883,902 13.00

14.00 Nursing and Allied Health Managed Care payment (see instruction) 0 14.00

15.00 Organ acquisition 0 15.00

16.00 Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 20) (see instructions) 0 16.00



19.00 Subtotal (line 17 less line 18). 9,883,902 19.00

20.00 Deductibles 28,300 20.00


22.00 Coinsurance 84,051 22.00


24.00 Allowable bad debts (exclude bad debts for professional services) (see instructions) 0 24.00



27.00 Subtotal (sum of lines 23 and 25) 9,771,551 27.00


29.00 Other pass through costs (see instructions) 31,200 29.00




32.00 Total amount payable to the provider (see instructions) 9,802,751 32.00



35.00 Balance due provider/program (line 32 minus the sum lines 33 and 34) 17,647 35.00

36.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2 0 36.00


50.00 Original outlier amount from Worksheet E-3, Part III, line 4 0 50.00





MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-4

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208DIRECT GRADUATE MEDICAL EDUCATION (GME) & ESRD OUTPATIENT DIRECT

MEDICAL EDUCATION COSTS


1.00

COMPUTATION OF TOTAL DIRECT GME AMOUNT

1.00 Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods

ending on or before December 31, 1996.

171.79 1.00

2.00 Unweighted FTE resident cap add-on for new programs per 42 CFR 413.79(e)(1) (see instructions) 41.73 2.00

3.00 Amount of reduction to Direct GME cap under section 422 of MMA 0.00 3.00

3.01 Direct GME cap reduction amount under ACA §5503 in accordance with CFR §413.79 (m). (see

instructions for cost reporting periods straddling 7/1/2011)

0.00 3.01

4.00 Adjustment (plus or minus) to the FTE cap for allopathic and osteopathic programs due to a Medicare

GME affiliation agreement (42 CFR §413.75(b) and § 413.79 (f))

0.00 4.00

4.01 ACA Section 5503 increase to the Direct GME FTE Cap (see instructions for cost reporting periods

straddling 7/1/2011)

0.00 4.01

4.02 ACA Section 5506 number of additional direct GME FTE cap slots (see instructions for cost reporting

periods straddling 7/1/2011)

0.00 4.02

5.00 FTE adjusted cap (line 1 plus line 2 minus line 3 and 3.01 plus or minus line 4 plus line 4.01 plus

line 4.02 plus applicable subscripts

213.52 5.00

6.00 Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your

records (see instructions)

214.23 6.00

7.00 Enter the lesser of line 5 or line 6 213.52 7.00

Primary Care Other Total

1.00 2.00 3.00

8.00 Weighted FTE count for physicians in an allopathic and osteopathic

program for the current year.

135.42 74.26 209.68 8.00

9.00 If line 6 is less than 5 enter the amount from line 8, otherwise

multiply line 8 times the result of line 5 divided by the amount on line

6.

134.97 74.01 208.98 9.00

10.00 Weighted dental and podiatric resident FTE count for the current year 0.00 10.00

11.00 Total weighted FTE count 134.97 74.01 11.00

12.00 Total weighted resident FTE count for the prior cost reporting year (see

instructions)

137.41 76.10 12.00

13.00 Total weighted resident FTE count for the penultimate cost reporting

year (see instructions)

136.73 69.93 13.00

14.00 Rolling average FTE count (sum of lines 11 through 13 divided by 3). 136.37 73.35 14.00

15.00 Adjustment for residents in initial years of new programs 0.00 0.00 15.00

16.00 Adjustment for residents displaced by program or hospital closure 0.00 0.00 16.00

17.00 Adjusted rolling average FTE count 136.37 73.35 17.00

18.00 Per resident amount 134,585.78 127,440.86 18.00

19.00 Approved amount for resident costs 18,353,463 9,347,787 27,701,250 19.00

1.00

20.00 Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42

Sec. 413.79(c )(4)

0.00 20.00

21.00 GME FTE weighted Resident count over Cap (see instructions) 0.71 21.00

22.00 Allowable additional direct GME FTE Resident Count (see instructions) 0.00 22.00

23.00 Enter the locally adjustment national average per resident amount (see instructions) 0.00 23.00

24.00 Multiply line 22 time line 23 0 24.00

25.00 Total direct GME amount (sum of lines 19 and 24) 27,701,250 25.00

Inpatient Part

A

Managed care

1.00 2.00 3.00

COMPUTATION OF PROGRAM PATIENT LOAD

26.00 Inpatient Days 81,310 10,618 26.00

27.00 Total Inpatient Days 204,992 204,992 27.00

28.00 Ratio of inpatient days to total inpatient days 0.396650 0.051797 28.00

29.00 Program direct GME amount 10,987,701 1,434,842 29.00

30.00 Reduction for nursing/allied health 202,743 30.00

31.00 Net Program direct GME amount 12,219,800 31.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet E-4

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208DIRECT GRADUATE MEDICAL EDUCATION (GME) & ESRD OUTPATIENT DIRECT

MEDICAL EDUCATION COSTS


1.00

DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING SCHOOL AND PARAMEDICAL

EDUCATION COSTS)

32.00 Renal dialysis direct medical education costs (from Worksheet B, Part I, sum of columns 20 and 23,

lines 74 and 94)

5,094 32.00

33.00 Renal dialysis and home dialysis total charges (Worksheet C, Part I, column 8, sum of lines 74 and

94)

8,128,811 33.00

34.00 Ratio of direct medical education costs to total charges (line 32 ÷ line 33) 0.000627 34.00

35.00 Medicare outpatient ESRD charges (see instructions) 0 35.00

36.00 Medicare outpatient ESRD direct medical education costs (line 34 x line 35) 0 36.00

APPORTIONMENT BASED ON MEDICARE REASONABLE COST - TITLE XVIII ONLY

Part A Reasonable Cost

37.00 Reasonable cost (see instructions) 215,416,186 37.00

38.00 Organ acquisition costs (Worksheet D-4, Part III, column 1, line 69) 0 38.00

39.00 Cost of teaching physicians (Worksheet D-5, Part II, column 3, line 20) 0 39.00

40.00 Primary payer payments (see instructions) 112,956 40.00

41.00 Total Part A reasonable cost (sum of lines 37 through 39 minus line 40) 215,303,230 41.00

Part B Reasonable Cost

42.00 Reasonable cost (see instructions) 31,436,031 42.00

43.00 Primary payer payments (see instructions) 4,037 43.00

44.00 Total Part B reasonable cost (line 42 minus line 43) 31,431,994 44.00

45.00 Total reasonable cost (sum of lines 41 and 44) 246,735,224 45.00

46.00 Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45) 0.872608 46.00

47.00 Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45) 0.127392 47.00

ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B

48.00 Total program GME payment (line 31) 12,219,800 48.00

49.00 Part A Medicare GME payment (line 46 x 48)(Title XVIII only)(see instructions) 10,663,095 49.00

50.00 Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions) 1,556,705 50.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet G

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208BALANCE SHEET (If you are nonproprietary and do not maintain

fund-type accounting records, complete the General Fund column only)

General Fund Specific

Purpose Fund

Endowment Fund Plant Fund

1.00 2.00 3.00 4.00

CURENT ASSETS

1.00 Cash on hand in banks 1.00163,733,000 0 0 0

2.00 Temporary investments 2.0064,573,000 0 0 0

3.00 Notes receivable 3.000 0 0 0

4.00 Accounts receivable 4.00373,497,000 0 0 0

5.00 Other receivable 5.000 0 0 0

6.00 Allowances for uncollectible notes and accounts receivable 6.000 0 0 0

7.00 Inventory 7.000 0 0 0

8.00 Prepaid expenses 8.000 0 0 0

9.00 Other current assets 9.00169,155,000 0 0 0

10.00 Due from other funds 10.0036,896,000 0 0 0

11.00 Total current assets (sum of lines 1-10) 11.00807,854,000 0 0 0

FIXED ASSETS

12.00 Land 12.0097,005,000 0 0 0

13.00 Land improvements 13.000 0 0 0

14.00 Accumulated depreciation 14.000 0 0 0

15.00 Buildings 15.001,771,448,000 0 0 0


17.00 Leasehold improvements 17.000 0 0 0


19.00 Fixed equipment 19.000 0 0 0


21.00 Automobiles and trucks 21.000 0 0 0


23.00 Major movable equipment 23.001,013,835,000 0 0 0

24.00 Accumulated depreciation 24.00-1,668,349,000 0 0 0

25.00 Minor equipment depreciable 25.000 0 0 0


27.00 HIT designated Assets 27.000 0 0 0


29.00 Minor equipment-nondepreciable 29.000 0 0 0

30.00 Total fixed assets (sum of lines 12-29) 30.001,213,939,000 0 0 0

OTHER ASSETS

31.00 Investments 31.003,266,326,000 0 0 0

32.00 Deposits on leases 32.000 0 0 0

33.00 Due from owners/officers 33.000 0 0 0

34.00 Other assets 34.00132,449,000 0 0 0

35.00 Total other assets (sum of lines 31-34) 35.003,398,775,000 0 0 0

36.00 Total assets (sum of lines 11, 30, and 35) 36.005,420,568,000 0 0 0

CURRENT LIABILITIES

37.00 Accounts payable 37.00157,906,000 0 0 0

38.00 Salaries, wages, and fees payable 38.00270,822,000 0 0 0

39.00 Payroll taxes payable 39.000 0 0 0

40.00 Notes and loans payable (short term) 40.00301,284,000 0 0 0

41.00 Deferred income 41.000 0 0 0

42.00 Accelerated payments 42.000

43.00 Due to other funds 43.000 0 0 0

44.00 Other current liabilities 44.00290,972,000 0 0 0

45.00 Total current liabilities (sum of lines 37 thru 44) 45.001,020,984,000 0 0 0

LONG TERM LIABILITIES

46.00 Mortgage payable 46.00966,446,000 0 0 0

47.00 Notes payable 47.000 0 0 0

48.00 Unsecured loans 48.000 0 0 0

49.00 Other long term liabilities 49.00826,415,000 0 0 0

50.00 Total long term liabilities (sum of lines 46 thru 49 50.001,792,861,000 0 0 0

51.00 Total liabilites (sum of lines 45 and 50) 51.002,813,845,000 0 0 0

CAPITAL ACCOUNTS

52.00 General fund balance 52.002,606,723,000

53.00 Specific purpose fund 53.000

54.00 Donor created - endowment fund balance - restricted 54.000

55.00 Donor created - endowment fund balance - unrestricted 55.000

56.00 Governing body created - endowment fund balance 56.000

57.00 Plant fund balance - invested in plant 57.000

58.00 Plant fund balance - reserve for plant improvement,

replacement, and expansion

58.000

59.00 Total fund balances (sum of lines 52 thru 58) 59.002,606,723,000 0 0 0

60.00 Total liabilities and fund balances (sum of lines 51 and

59)

60.005,420,568,000 0 0 0


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet G-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208STATEMENT OF CHANGES IN FUND BALANCES

General Fund Special Purpose Fund

1.00 2.00 3.00 4.00

1.00 Fund balances at beginning of period 2,535,942,400 0 1.00

2.00 Net income (loss) (from Wkst. G-3, line 29) 70,780,600 2.00

3.00 Total (sum of line 1 and line 2) 2,606,723,000 0 3.00

4.00 Additions (credit adjustments) (specify) 0 0 4.00

5.00 0 0 5.00

6.00 0 0 6.00

7.00 0 0 7.00

8.00 0 0 8.00

9.00 0 0 9.00

10.00 Total additions (sum of line 4-9) 0 0 10.00

11.00 Subtotal (line 3 plus line 10) 2,606,723,000 0 11.00

12.00 Deductions (debit adjustments) (specify) 0 0 12.00

13.00 0 0 13.00

14.00 0 0 14.00

15.00 0 0 15.00

16.00 0 0 16.00

17.00 0 0 17.00

18.00 Total deductions (sum of lines 12-17) 0 0 18.00

19.00 Fund balance at end of period per balance

sheet (line 11 minus line 18)

2,606,723,000 0 19.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet G-1

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208STATEMENT OF CHANGES IN FUND BALANCES

Endowment Fund Plant Fund

5.00 6.00 7.00 8.00

1.00 Fund balances at beginning of period 0 0 1.00

2.00 Net income (loss) (from Wkst. G-3, line 29) 2.00

3.00 Total (sum of line 1 and line 2) 0 0 3.00

4.00 Additions (credit adjustments) (specify) 0 0 4.00

5.00 0 0 5.00

6.00 0 0 6.00

7.00 0 0 7.00

8.00 0 0 8.00

9.00 0 0 9.00

10.00 Total additions (sum of line 4-9) 0 0 10.00

11.00 Subtotal (line 3 plus line 10) 0 0 11.00

12.00 Deductions (debit adjustments) (specify) 0 0 12.00

13.00 0 0 13.00

14.00 0 0 14.00

15.00 0 0 15.00

16.00 0 0 16.00

17.00 0 0 17.00

18.00 Total deductions (sum of lines 12-17) 0 0 18.00

19.00 Fund balance at end of period per balance

sheet (line 11 minus line 18)

0 0 19.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet G-2 Parts

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES

Cost Center Description Inpatient Outpatient Total

1.00 2.00 3.00

PART I - PATIENT REVENUES

General Inpatient Routine Services

1.00 Hospital 260,147,636 260,147,636 1.00

2.00 SUBPROVIDER - IPF 15,512,871 15,512,871 2.00

3.00 SUBPROVIDER - IRF 15,763,100 15,763,100 3.00


5.00 Swing bed - SNF 0 0 5.00

6.00 Swing bed - NF 0 0 6.00




10.00 Total general inpatient care services (sum of lines 1-9) 291,423,607 291,423,607 10.00

Intensive Care Type Inpatient Hospital Services







16.00 Total intensive care type inpatient hospital services (sum of lines

11-15)

145,889,666 145,889,666 16.00

17.00 Total inpatient routine care services (sum of lines 10 and 16) 437,313,273 437,313,273 17.00

18.00 Ancillary services 1,265,133,024 525,536,861 1,790,669,885 18.00

19.00 Outpatient services 78,166,053 104,169,125 182,335,178 19.00




23.00 AMBULANCE SERVICES 23.00

24.00 CMHC 24.00

24.10 CORF 0 0 0 24.10


26.00 HOSPICE 26.00

27.00 AMBULATORY CARE 123,893 6,142,685 6,266,578 27.00

28.00 Total patient revenues (sum of lines 17-27)(transfer column 3 to Wkst.

G-3, line 1)

1,780,736,243 635,848,671 2,416,584,914 28.00

PART II - OPERATING EXPENSES

29.00 Operating expenses (per Wkst. A, column 3, line 200) 814,673,073 29.00

30.00 ADD (SPECIFY) 0 30.00

31.00 0 31.00

32.00 0 32.00

33.00 0 33.00

34.00 0 34.00

35.00 0 35.00

36.00 Total additions (sum of lines 30-35) 0 36.00

37.00 DEDUCT (SPECIFY) 0 37.00

38.00 0 38.00

39.00 0 39.00

40.00 0 40.00

41.00 0 41.00

42.00 Total deductions (sum of lines 37-41) 0 42.00

43.00 Total operating expenses (sum of lines 29 and 36 minus line 42)(transfer

to Wkst. G-3, line 4)

814,673,073 43.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet G-3

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208STATEMENT OF REVENUES AND EXPENSES

1.00

1.00 Total patient revenues (from Wkst. G-2, Part I, column 3, line 28) 2,416,584,914 1.00

2.00 Less contractual allowances and discounts on patients' accounts 1,545,102,653 2.00

3.00 Net patient revenues (line 1 minus line 2) 871,482,261 3.00

4.00 Less total operating expenses (from Wkst. G-2, Part II, line 43) 814,673,073 4.00

5.00 Net income from service to patients (line 3 minus line 4) 56,809,188 5.00

OTHER INCOME

6.00 Contributions, donations, bequests, etc 0 6.00

7.00 Income from investments 0 7.00

8.00 Revenues from telephone and telegraph service 0 8.00

9.00 Revenue from television and radio service 0 9.00

10.00 Purchase discounts 0 10.00

11.00 Rebates and refunds of expenses 0 11.00

12.00 Parking lot receipts 0 12.00

13.00 Revenue from laundry and linen service 0 13.00

14.00 Revenue from meals sold to employees and guests 0 14.00

15.00 Revenue from rental of living quarters 0 15.00

16.00 Revenue from sale of medical and surgical supplies to other than patients 0 16.00

17.00 Revenue from sale of drugs to other than patients 0 17.00

18.00 Revenue from sale of medical records and abstracts 0 18.00

19.00 Tuition (fees, sale of textbooks, uniforms, etc.) 0 19.00

20.00 Revenue from gifts, flowers, coffee shops, and canteen 0 20.00

21.00 Rental of vending machines 0 21.00

22.00 Rental of hospital space 0 22.00

23.00 Governmental appropriations 0 23.00

24.00 OTHER OPERATING 14,186,083 24.00

25.00 Total other income (sum of lines 6-24) 14,186,083 25.00

26.00 Total (line 5 plus line 25) 70,995,271 26.00

27.00 NET NONOPERATING LOSS 214,671 27.00

28.00 Total other expenses (sum of line 27 and subscripts) 214,671 28.00

29.00 Net income (or loss) for the period (line 26 minus line 28) 70,780,600 29.00


MCRIF32 - 2.25.130.0


Date/Time Prepared:

Worksheet L

Parts I-III

5/24/2012 1:29 pm

Period:

To

From 01/01/2011

12/31/2011

Provider CCN: 140208CALCULATION OF CAPITAL PAYMENT


1.00

PART I - FULLY PROSPECTIVE METHOD

CAPITAL FEDERAL AMOUNT

1.00 Capital DRG other than outlier 10,538,043 1.00

2.00 Capital DRG outlier payments 168,326 2.00

3.00 Total inpatient days divided by number of days in the cost reporting period (see instructions) 501.01 3.00

4.00 Number of interns & residents (see instructions) 213.92 4.00

5.00 Indirect medical education percentage (see instructions) 12.81 5.00

6.00 Indirect medical education adjustment (line 1 times line 5) 1,349,923 6.00

7.00 Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, part A line

30) (see instructions)

3.81 7.00

8.00 Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I (see

instructions)

27.22 8.00

9.00 Sum of lines 7 and 8 31.03 9.00

10.00 Allowable disproportionate share percentage (see instructions) 6.49 10.00

11.00 Disproportionate share adjustment (line 1 times line 10) 683,919 11.00

12.00 Total prospective capital payments (sum of lines 1-2, 6, and 11) 12,740,211 12.00

1.00

PART II - PAYMENT UNDER REASONABLE COST

1.00 Program inpatient routine capital cost (see instructions) 0 1.00

2.00 Program inpatient ancillary capital cost (see instructions) 0 2.00

3.00 Total inpatient program capital cost (line 1 plus line 2) 0 3.00

4.00 Capital cost payment factor (see instructions) 0 4.00

5.00 Total inpatient program capital cost (line 3 x line 4) 0 5.00

1.00

PART III - COMPUTATION OF EXCEPTION PAYMENTS

1.00 Program inpatient capital costs (see instructions) 0 1.00

2.00 Program inpatient capital costs for extraordinary circumstances (see instructions) 0 2.00

3.00 Net program inpatient capital costs (line 1 minus line 2) 0 3.00

4.00 Applicable exception percentage (see instructions) 0.00 4.00

5.00 Capital cost for comparison to payments (line 3 x line 4) 0 5.00

6.00 Percentage adjustment for extraordinary circumstances (see instructions) 0.00 6.00

7.00 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6) 0 7.00

8.00 Capital minimum payment level (line 5 plus line 7) 0 8.00

9.00 Current year capital payments (from Part I, line 12, as applicable) 0 9.00

10.00 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) 0 10.00

11.00 Carryover of accumulated capital minimum payment level over capital payment (from prior year

Worksheet L, Part III, line 14)

0 11.00

12.00 Net comparison of capital minimum payment level to capital payments (line 10 plus line 11) 0 12.00

13.00 Current year exception payment (if line 12 is positive, enter the amount on this line) 0 13.00

14.00 Carryover of accumulated capital minimum payment level over capital payment for the following period

(if line 12 is negative, enter the amount on this line)

0 14.00

15.00 Current year allowable operating and capital payment (see instructions) 0 15.00

16.00 Current year operating and capital costs (see instructions) 0 16.00

17.00 Current year exception offset amount (see instructions) 0 17.00


MCRIF32 - 2.25.130.0

health financial systems in lieu of form cms-2552-10 ...€¦ · in column 2, enter "y"...

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